Autopsy causes of death in HIV-positive individuals in Sub-Saharan Africa and correlation with clinical diagnoses

Institute of Tropical Medicine, Antwerp, Belgium.
AIDS reviews (Impact Factor: 3.79). 10/2010; 12(4):183-94.
Source: PubMed


Despite the persistently high HIV-related mortality in sub-Saharan Africa, limited information on the causes of death is available. Pathological autopsies are the gold standard to establish causes of death. In this review we describe the autopsy series performed among HIV-infected individuals in sub-Saharan Africa over the last two decades. We identified nine complete and 11 partial or minimally invasive autopsy series. Complete autopsies were performed in 593 HIV-positive adults and 177 HIV-positive children. Postmortem diagnoses were mainly infectious diseases. Tuberculosis was the most frequent, present in 21-54% of HIV-positive adults and was considered the cause of death in 32-45%. Overall, pulmonary infections accounted for approximately 66% of pathology and central nervous system infections for approximately 20%. A high discordance between clinical and postmortem diagnoses was observed. This review emphasizes the need for reliable information on causes of death in order to improve HIV patient care, guide further research, and inform health policy.

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Available from: Robert Lukande, Oct 06, 2015
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    • "Nontuberculous mycobacterium (NTM) is a ubiquitous environmental organism and the majority of organisms within this family are not pathological in humans [1] [2]. The route of entry in human hosts is by inhalation or ingestion, depending on the species [3]. "
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    ABSTRACT: The prevalence of nontuberculous mycobacteria infection (NTM) in Sub-Saharan Africa is estimated to be less than 1%. NTM is often underdiagnosed or misdiagnosed as tuberculosis in patients who present with immune reconstitution syndrome (IRS) following initiation of antiretroviral treatment (ART). Immune reconstitution syndrome is common in patients who start ART with low CD4 counts and high HIV viral load. Furthermore, Mycobacterium avium complex (MAC) commonly infects those with CD4 counts less than 50 cells/mm(3). Three patients, with low baseline CD4 counts, presenting with NTM following the initiation of antiretroviral treatment are described in this case series. The first patient presented with disseminated NTM two weeks after commencing antiretroviral treatment. Acid fast bacilli were found in the liver, duodenum, and bone marrow and were suggestive of MAC microscopically. The second developed cervical lymphadenitis following the initiation of ART. Lymph node aspirate culture grew NTM. The last patient developed pancytopenia after 3 months of ART. AFB was seen on bone marrow biopsy. Culture of the bone marrow aspirate was suggestive of NTM. All three patients improved on ethambutol, clarithromycin, and rifampicin. NTM may be underdiagnosed in areas with a high TB prevalence and should be actively excluded by culture.
    Case Reports in Medicine 11/2014; 2014:964612. DOI:10.1155/2014/964612
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    • "An autopsy series from South Africa showed that the top three ranked causes of death among HIV-positive people were TB, pneumonia, and meningitis (20) and the same pattern was observed in a smaller series in Uganda (21). A review of autopsy studies in Africa showed that TB, pneumonia, and meningitis were major causes of death among HIV-positive people, though there were major discrepancies between hospital causes of death and pathology findings (22). Similar causes of death patterns have been observed in hospital patient series in Thailand (23) and South Africa (24). "
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    ABSTRACT: Reliable population-based data on HIV infection and AIDS mortality in sub-Saharan Africa are scanty, even though that is the region where most of the world's AIDS deaths occur. There is therefore a great need for reliable and valid public health tools for assessing AIDS mortality. The aim of this article is to validate the InterVA-4 verbal autopsy (VA) interpretative model within African populations where HIV sero-status is recorded on a prospective basis, and examine the distribution of cause-specific mortality among HIV-positive and HIV-negative people. Data from six sites of the Alpha Network, including HIV sero-status and VA interviews, were pooled. VA data according to the 2012 WHO format were extracted, and processed using the InterVA-4 model into likely causes of death. The model was blinded to the sero-status data. Cases with known pre-mortem HIV infection status were used to determine the specificity with which InterVA-4 could attribute HIV/AIDS as a cause of death. Cause-specific mortality fractions by HIV infection status were calculated, and a person-time model was built to analyse adjusted cause-specific mortality rate ratios. The InterVA-4 model identified HIV/AIDS-related deaths with a specificity of 90.1% (95% CI 88.7-91.4%). Overall sensitivity could not be calculated, because HIV-positive people die from a range of causes. In a person-time model including 1,739 deaths in 1,161,688 HIV-negative person-years observed and 2,890 deaths in 75,110 HIV-positive person-years observed, the mortality ratio HIV-positive:negative was 29.0 (95% CI 27.1-31.0), after adjustment for age, sex, and study site. Cause-specific HIV-positive:negative mortality ratios for acute respiratory infections, HIV/AIDS-related deaths, meningitis, tuberculosis, and malnutrition were higher than the all-cause ratio; all causes had HIV-positive:negative mortality ratios significantly higher than unity. These results were generally consistent with relatively small post-mortem and hospital-based diagnosis studies in the literature. The high specificity in cause of death attribution achieved in relation to HIV status, and large differences between specific causes by HIV status, show that InterVA-4 is an effective and valid tool for assessing HIV-related mortality.
    Global Health Action 10/2013; 6:22448. DOI:10.3402/gha.v6i0.22448 · 1.93 Impact Factor
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    • "Autopsy rates have been declining worldwide due to advances in diagnostic techniques, administrative and legislative difficulties and negative publicity on tissue retention among others (Burton & Underwood 2007). In sub-Saharan Africa (SSA), additional factors play a role such as the limited number of pathology services, lack of trained personnel and insufficient resources (Nelson & Kalengayi 1994; Cox et al. 2010). Nonetheless, reliable information on causes of death is essential to inform health policy and allocate the scarce health resources in resource-limited settings. "
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    ABSTRACT: Objective To determine the autopsy acceptance rate and reasons for decline at Mulago Hospital, Kampala, Uganda. Methods The next of kin of patients who died in a combined infectious diseases and gastro-enterology ward of Mulago Hospital were approached to answer a questionnaire concerning characteristics of their deceased relative. During the interview their consent was asked to perform a complete autopsy. If autopsy was declined, the next of kin were asked to provide their reason for the decline. Results Permission to perform an autopsy was requested in 158 (54%) of the 290 deaths that occurred during the study period. In 60 (38%) cases autopsy was accepted. Fifty-nine autopsies were performed. For 82% of refusals a reason was listed; mainly ‘not wanting to delay the burial’ (58%), ‘no use to know the cause of death’ (16%) and ‘being satisfied with the clinical cause of death’ (10%). Conclusion The autopsy rate achieved under study conditions was 38% compared to rates of 5% in Mulago Hospital over the past decade. Timely request and rapid performance of autopsies appear to be important determinants of autopsy acceptance. A motivated team of pathologists and clinicians is required to increase autopsy acceptance. Objectif: Déterminer le taux d’acceptation de l’autopsie et les raisons du refus à l’hôpital de Mulago, Kampala, Ouganda. Méthodes: Les proches de patients décédés dans un service combiné de maladies infectieuses et de gastro-entérologie de l’hôpital de Mulago ont été contactés pour répondre à un questionnaire concernant les caractéristiques de leur parent décédé. Au cours de l’entretien, leur consentement a été demandé afin d’effectuer une autopsie complète. Dans le cas d’un refus, les proches ont été invités à donner leur raison. Résultats: L’autorisation de procéder à une autopsie a été demandée pour 158 (54%) des 290 décès survenus pendant la période d’étude. Dans 60 (38%) des cas, l’autopsie a été acceptée. 59 autopsies ont été pratiquées. Pour 82% des cas de refus un motif a été répertoriée, principalement: «pour ne pas retarder l’enterrement” (58%), «inutilité de connaître la cause de décès» (16%) et «satisfait avec la cause médicale donnée pour le décès» (10%). Conclusion: Le taux d’autopsies réalisées dans les conditions de l’étude était de 38% par rapport au taux de 5% dans l’hôpital de Mulago au cours des dix dernières années. La demande en temps opportun et la réalisation rapide des autopsies semblent être des déterminants importants de l’acceptation de l’autopsie. Une équipe de pathologistes et de cliniciens motivés est nécessaire pour accroître l’acceptation de l’autopsie.
    Tropical Medicine & International Health 05/2011; 16(8):1015 - 1018. DOI:10.1111/j.1365-3156.2011.02798.x · 2.33 Impact Factor
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