Short-term risk of AIDS or death in people infected with HIV-1 before antiretroviral therapy in South Africa: a longitudinal study

Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa.
The Lancet (Impact Factor: 39.21). 11/2006; 368(9543):1254-9. DOI: 10.1016/S0140-6736(06)69117-4
Source: PubMed

ABSTRACT In sub-Saharan Africa, data for short-term risk of AIDS or death, which might inform decisions about when to start antiretroviral therapy (ART), are scarce. Our aim was to investigate these risks in patients who had no access to ART or who were given zidovudine alone.
6-month risks (%) of death, AIDS, and combined risk of AIDS and death (AIDS/death) were calculated according to CD4-cell count category of less than 200 cells per microL, 200-350 cells per microL, or greater than 350 cells per microL, stratified by WHO clinical stages 1 and 2 combined, 3, or 4 in untreated patients (n=1399) seeking care in tertiary public-sector HIV clinics before widespread availability of ART in Cape Town, South Africa.
Risk of death for WHO stages 1 and 2 was 3.5% for those with less than 200 cells per microL, 2.8% for 200-350 cells per microL, and 1.2% for greater than 350 cells per microL. The corresponding rates for WHO stage 3 were 10.8%, 4.3%, and 4.9% and for stage 4, 22.2%, 10.3%, and 13.8%. 52% (90) of deaths took place in patients without AIDS. 6-month risk of AIDS for WHO stages 1 and 2 was 3.5% for those with less than 200 cells per microL, 1.6% for 200-350 cells per microL, and zero for greater than 350 cells per microL. The corresponding rates for those with WHO stage 3 disease were 17.4%, 7.0%, and 2.2%.
In this study, risk of AIDS in patients with a CD4-cell count of less than 200 cells per microL or greater than 350 cells per microL was similar to that previously reported from European cohorts, but was 1.9 times greater for those with CD4-cell counts of between 200 and 350 cells per microL. The high death rate before development of AIDS and a high risk of AIDS in those with CD4-cell counts of 200-350 cells per microL indicate that delay in initiation of ART is associated with increased morbidity and mortality. These findings might help to amend criteria for start of ART in resource-limited settings.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: This systematic review summarizes evidence on the effectiveness of strategies to increase men's HIV-testing in sub-Saharan Africa. Methods: Medline, EmBase, Africa-Wide Information and Global Health were searched. Cluster and individually randomized trials evaluating interventions to increase the proportion of adults (>15 years) testing for HIV were eligible if they were conducted in sub-Saharan Africa, included men in the study population, and reported HIV-testing data by sex. References were independently screened. Results: Of the 1852 references, 15 papers including 16 trials were eligible. Trials were judged too heterogeneous to combine in meta-analysis. Three interventions invited men to attend antenatal care-based HIV-testing via pregnant partners, of which two showed a significant effect on partner-testing. One intervention invited men to HIV-test through pregnant partners and showed an increase in HIV-testing when it was offered in bars compared with health facilities. A trial of notification to partners of newly diagnosed HIV-positive patients showed an increase in testing where notification was by healthcare providers compared with notification by the patient. Three interventions reached men already at health facilities and eight reported the effects of community-based HIV-testing. Mobile-testing had a significant effect on HIV-testing compared with standard voluntary counselling and testing. Home-based testing also had a significant effect, but reached smaller numbers of men than mobile-testing. Discussion: Interventions to encourage HIV-testing can increase men's levels of HIV-testing. Community-based programmes in particular had a large effect on population levels of HIV-testing. More data on costs and potential population impact of these approaches over different time-horizons would aid policy-makers in planning resource allocation to increase male HIV-testing. (C) 2014 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins
    AIDS (London, England) 07/2014; 28(14). DOI:10.1097/QAD.0000000000000395 · 6.56 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background The Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing.MethodsA total of 1,752 adults aged over 15 years who tested HIV positive through VCT services or the IPC, and subsequently registered at initial clinic visit between September 2008 and September 2010, were considered in the analysis. Multivariable logistic regression models were developed to assess the association of CD4 count and WHO clinical stage of HIV infection at first clinic appointment with age group, gender, marital status and HIV testing source.ResultsMale gender and marital status were independently associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 count ¿350 cells/¿l) at initial clinic visit. Patients testing HIV positive during the IPC had significantly higher mean CD4 count at initial clinic visit compared to individuals who tested HIV positive via VCT services. Patients testing HIV positive during the IPC had more than two times higher odds of presenting early with CD4 count greater than 350 cells/¿l (adjusted OR 2.15, 95% CI 1.28 ¿ 3.61, p = 0.004) and presenting early with WHO clinical stage 1 or 2 of HIV infection (adjusted OR 2.39, 95% CI 1.24 ¿ 4.60, p = 0.01) at initial clinic visit compared to individuals who tested HIV positive via VCT services.Conclusion The community-based integrated prevention campaign identified HIV positive individuals earlier in the course of HIV infection, compared to Voluntary Counselling and Testing services. Community-based campaigns, such as the IPC, may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.
    BMC Public Health 01/2015; 15(1):16. DOI:10.1186/s12889-015-1367-4 · 2.32 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Factors associated with mortality in HIV-infected people in sub-Saharan Africa are widely reported. However rural-urban disparities and their association with all-cause mortality remain unclear. Furthermore, commonly used classical Cox regression ignores unmeasured variables and frailty. Objective: To incorporate frailty in assessing factors associated with mortality in HIV-infected people in rural and urban South Africa. Design: Using data from a prospective cohort following 6,690 HIV-infected participants from Soweto (urban) and Mpumalanga (rural) enrolled from 2003 to 2010; covariates of mortality were assessed by the integrated nested Laplace approximation method. Results: We enrolled 2,221 (33%) rural and 4,469 (67%) urban participants of whom 1,555 (70%) and 3,480 (78%) were females respectively. Median age (IQR) was 36.4 (31.0-44.1) in rural and 32.7 (28.2-38.1) in the urban participants. The mortality rate per 100 person-years was 11 (9.7-12.5) and 4 (3.6-4.5) in the rural and urban participants, respectively. Compared to those not on HAART, rural participants had a reduced risk of mortality if on HAART for 6-12 (HR: 0.20, 95% CI: 0.10-0.39) and >12 months (HR: 0.10, 95% CI: 0.05-0.18). Relative to those not on HAART, urban participants had a lower risk if on HAART >12 months (HR: 0.35, 95% CI: 0.27-0.46). The frailty variance was significant and >1 in rural participants indicating more heterogeneity. Similarly it was significant but <1 in the urban participants indicating less heterogeneity. Conclusion: The frailty model findings suggest an elevated risk of mortality in rural participants relative to the urban participants potentially due to unmeasured variables that could be biological, socio-economic, or healthcare related. Use of robust methods that optimise data and account for unmeasured variables could be helpful in assessing the effect of unknown risk factors thus improving patient management and care in South Africa and elsewhere.
    Global Health Action 09/2014; 7:25488. DOI:10.3402/gha.v7.25488 · 1.65 Impact Factor


Available from
Jul 10, 2014