Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: A prospective cohort study

Centers for Disease Control and Prevention-Uganda, Global AIDS Program, National Center for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Entebbe, Uganda.
The Lancet (Impact Factor: 45.22). 03/2008; 371(9614):752-9. DOI: 10.1016/S0140-6736(08)60345-1
Source: PubMed

ABSTRACT Antiretroviral therapy (ART) is increasingly available in Africa, but physicians and clinical services are few. We therefore assessed the effect of a home-based ART programme in Uganda on mortality, hospital admissions, and orphanhood in people with HIV-1 and their household members.
In 2001, we enrolled and followed up 466 HIV-infected adults and 1481 HIV-uninfected household members in a prospective cohort study. After 5 months, we provided daily co-trimoxazole (160 mg trimethoprim and 800 mg sulfamethoxazole) prophylaxis to HIV-infected participants. Between May, 2003, and December, 2005, we followed up 138 infected adults who were eligible and 907 new HIV-infected participants and their HIV-negative household members in a study of ART (mainly stavudine, lamivudine, and nevirapine). Households were visited every week by lay providers, and no clinic visits were scheduled after enrolment. We compared rates of death, hospitalisation, and orphanhood during different study periods and calculated the number needed to treat to prevent an outcome.
233 (17%) of 1373 participants with HIV and 40 (1%) of 4601 HIV-uninfected household members died. During the first 16 weeks of ART and co-trimoxazole, mortality in HIV-infected participants was 55% lower than that during co-trimoxazole alone (14 vs 16 deaths per 100 person-years; adjusted hazard ratio 0.45, 95% CI 0.27-0.74, p=0.0018), and after 16 weeks, was reduced by 92% (3 vs 16 deaths per 100 person-years; 0.08, 0.06-0.13, p<0.0001). Compared with no intervention, ART and co-trimoxazole were associated with a 95% reduction in mortality in HIV-infected participants (5 vs 27 deaths per 100 person-years; 0.05, 0.03-0.08, p<0.0001), 81% reduction in mortality in their uninfected children younger than 10 years (0.2 vs 1.2 deaths per 100 person-years; 0.19, 0.06-0.59, p=0.004), and a 93% estimated reduction in orphanhood (0.9 vs 12.8 per 100 person-years of adults treated; 0.07, 0.04-0.13, p<0.0001).
Expansion of access to ART and co-trimoxazole prophylaxis could substantially reduce mortality and orphanhood among adults with HIV and their families living in resource-poor settings.

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    • "Such strategies include malaria management for effective treatment in Africa (Hopkins, Talisuna, Whitty, & Staedke, 2007; Kidane & Morrow, 2000), neonatal care (Bang et al., 2005), reduction of maternal mortality (Goldie, Sweet, Carvalho, Natchu, & Hu, 2010), sexual and reproductive health services for men and women (Bell, Mthembu, O'Sullivan, & Moody, 2007), and concurrent therapy for HIV and tuberculosis (Gandhi et al., 2009). Home-based antiretroviral treatment (ART) has been shown to be effective in reducing mortality and hospital admissions (Mermin et al., 2008), but has relatively low cost-effectiveness (Marseille et al., 2009). Similarly, home-based HIV counselling and testing for household members of HIV-infected individuals has been reported to be feasible and have a higher uptake than clinic-based counselling and testing (Lugada et al., 2010). "
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