Article

Lawn SD, Harries AD, Anglaret X, Myer L, Wood R. Early mortality among adults accessing antiretroviral treatment programmes in sub-Saharan Africa

aDesmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa bClinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK cHIV Unit, Ministry of Health, Malawi dFamily Health International, Malawi Country Office, Lilongwe, Malawi eProgramme PAC-CI, Abidjan, Ivory Coast, France fINSERM, Unité 897, Centre de Recherche Epidémiologie et Biostatistique, Bordeaux, France gInfectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa hDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA.
AIDS (London, England) (Impact Factor: 6.56). 11/2008; 22(15):1897-908. DOI: 10.1097/QAD.0b013e32830007cd
Source: PubMed

ABSTRACT Two-thirds of the world's HIV-infected people live in sub-Saharan Africa, and more than 1.5 million of them die annually. As access to antiretroviral treatment has expanded within the region; early pessimism concerning the delivery of antiretroviral treatment using a large-scale public health approach has, at least in the short term, proved to be broadly unfounded. Immunological and virological responses to ART are similar to responses in patients treated in high-income countries. Despite this, however, early mortality rates in sub-Saharan Africa are very high; between 8 and 26% of patients die in the first year of antiretroviral treatment, with most deaths occurring in the first few months. Patients typically access antiretroviral treatment with advanced symptomatic disease, and mortality is strongly associated with baseline CD4 cell count less than 50 cells/mul and WHO stage 4 disease (AIDS). Although data are limited, leading causes of death appear to be tuberculosis, acute sepsis, cryptococcal meningitis, malignancy and wasting syndrome. Mortality rates are likely to depend not only on the care delivered by antiretroviral treatment programmes, but more fundamentally on how advanced disease is at programme enrollment and the quality of preceding healthcare. In addition to improving delivery of antiretroviral treatment and providing it free of charge to the patient, strategies to reduce mortality must include earlier diagnosis of HIV infection, strengthening of longitudinal HIV care and timely initiation of antiretroviral treatment. Health systems delays in antiretroviral treatment initiation must be minimized, especially in patients who present with advanced immunodeficiency.

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    • "Risk factors for IRIS include disseminated OI disease; recent OI treatment; low baseline CD4 with rapid rise after starting cART; and high baseline HIV VL with rapid decline after starting cART [14] [17] [20] [21]. Paradoxical IRIS in HIV-positive patients with previously treated cryptococcal disease has been estimated between 4 and 30% and is associated with an exaggerated T-cell mediated production of interferon-gamma to pathogen specific antigens [10] [12] [18] [22] [23]. The most common presentations of cryptococcal IRIS are either meningitis or lymphadenitis [24]. "
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    03/2014; 2014:164826. DOI:10.1155/2014/164826
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    • "Early mortality in the initial 90 days after antiretroviral therapy (ART) initiation is strikingly high among persons with low body mass index (BMI < 18.5 kg/m 2 ) compared to those with normal BMI [1] [2] [3] [4]. While a greater incidence of opportunistic infections and more advanced immunosuppression likely contributes to increased mortality in undernourished patients [5] [6], the loss of metabolically active tissue may negatively impact a range of critical physiologic processes and also contribute to these early deaths [7] [8] [9]. "
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    • "Our case studies therefore suggest that a synergistic relationship may exist between timeous receipt of this grant and improved health outcomes on ART. Several studies have shown that the first six months to a year of treatment is crucial and determines whether the treatment will be successful; those who survive this period have a reduced risk of both morbidity and mortality (Bussmann et al., 2008; Lawn et al., 2008). Our case studies show that timely receipt of the disability grant enabled household members to respond to the nutritional and health care needs of the sick member during this decisive period. "
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