Determinants of Early and Late Mortality Among HIV-Infected Individuals Receiving Home-Based Antiretroviral Therapy in Rural Uganda
Up to 20% of people initiating antiretroviral therapy (ART) in sub-Saharan Africa die during the first year of treatment. Understanding the clinical conditions associated with mortality could potentially lead to effective interventions to prevent these deaths.
We examined data from participants aged ≥18 years in the Home-Based AIDS Care project in Tororo, Uganda, to describe mortality over time and to determine clinical conditions associated with death. Survival analysis was used to examine variables associated with mortality at baseline and during follow-up.
A total of 112 (9.4%) deaths occurred in 1132 subjects (73% women) during a median of 3.0 years of ART. Mortality was 15.9 per 100 person-years during the first 3 months and declined to 0.3 per 100 person-years beyond 24 months after ART initiation. Tuberculosis (TB) was the most common condition associated with death (21% of deaths), followed by Candida disease (15%). In 43% of deaths, no specific clinical diagnosis was identified. Deaths within 3 months after ART initiation were associated with World Health Organization clinical stage III or IV at baseline, diagnosis of TB at baseline, a diagnosis of a non-TB opportunistic infection in follow-up and a body mass index ≤17 kg/m² during follow-up. Mortality after 3 months of ART was associated with CD4 cell counts <200 cells per microliter, a diagnosis of TB or other opportunistic infection, adherence to therapy <95%, and low hemoglobin levels during follow-up.
Potentially remediable conditions and preventable infections were associated with mortality while receiving ART in Uganda.
Available from: Walter Kipp
- "The TB program is poorly funded in this area of Uganda, reflecting the low political priority placed on TB by the government and by NGOs. This is surprising, given that HIV/AIDS has been declared a top priority by the Ugandan government (Ministry of Health, 2006), and that TB is the leading cause of death in HIV patients (Moore et al., 2011). Instead of integrating HIV and TB programs, the disproportionate focus on HIV (by both government and NGOs) is likely detracting from TB services, as has been shown to be the case for other aspects of primary health care in Kabarole district (Williams, 2009). "
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ABSTRACT: Uganda is one of the high burden countries that contribute 80% of the world’s tuberculosis (TB) burden. Health care worker and patient perspectives provide valuable insight into gaps between policy and practice within tuberculosis control program. This study was part of a larger mixedmethods study to explore knowledge and stigma around HIV, TB and TB/HIV co-infection. We conducted a secondary analysis of the qualitative data. Findings related to challenges faced by health care workers and patients. Patient’s identified delays in diagnosis and financial burden associated with TB treatment. Health care workers called for more training on TB and TB/HIV co-infection, and identified poor referral practices between health units and lack of program funding resulting in the abandonment of DOTS programs. Training for health care workers is needed to better manage TB/HIV co-infected patients. Overall health system strengthening is needed, including referral systems tracking patients between health centers.
Available from: Thomas Holland
- "Sixty-nine percent (23.5 million of 34 million) of all people infected with HIV worldwide and the majority of HIV-related deaths are in SSA . Infectious and immunological factors have usually been associated with the highest risk of death in people living with HIV in SSA [9,10]. However, HIV+ individuals without AIDS in SSA can now achieve a near normal life expectancy and hypertension is not uncommon [11,12]. "
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Mortality among people with human immunodeficiency virus (HIV) infection is increasingly due to non-communicable causes. This has been observed mostly in developed countries and the routine care of HIV infected individuals has now expanded to include attention to cardiovascular risk factors. Cardiovascular risk factors such as high blood pressure are often overlooked among HIV seropositive (+) individuals in sub-Saharan Africa. We aimed to determine the effect of blood pressure on mortality among HIV+ adults in Kenya.
We performed a retrospective analysis of electronic medical records of a large HIV treatment program in western Kenya between 2005 and 2010. All included individuals were HIV+. We excluded participants with AIDS, who were <16 or >80 years old, or had data out of acceptable ranges. Missing data for key covariates was addressed by inverse probability weighting. Primary outcome measures were crude mortality rate and mortality hazard ratio (HR) using Cox proportional hazards models adjusted for potential confounders including HIV stage.
There were 49,475 (74% women) HIV+ individuals who met inclusion and exclusion criteria. Mortality rates for men and women were 3.8 and 1.8/100 person-years, respectively, and highest among those with the lowest blood pressures. Low blood pressure was associated with the highest mortality incidence rate (IR) (systolic <100 mmHg IR 5.2 [4.8-5.7]; diastolic <60 mmHg IR 9.2 [8.3-10.2]). Mortality rate among men with high systolic blood pressure without advanced HIV (3.0, 95% CI: 1.6-5.5) was higher than men with normal systolic blood pressure (1.1, 95% CI: 0.7-1.7). In weighted proportional hazards regression models, men without advanced HIV disease and systolic blood pressure ≥140 mmHg carried a higher mortality risk than normotensive men (HR: 2.39, 95% CI: 0.94-6.08).
Although there has been little attention paid to high blood pressure among HIV+ Africans, we show that blood pressure level among HIV+ patients in Kenya is related to mortality. Low blood pressure carries the highest mortality risk. High systolic blood pressure is associated with mortality among patients whose disease is not advanced. Further investigation is needed into the cause of death for such patients.
Available from: Kye-Hyung Kim
- "During the first year after ART initiation, CDC clinical categories B or C on ART initiation and underlying malignancy were significant risk factors for death. The patients with clinical category C were about 22 times more likely to die than those with clinical category A. These findings are consistent with other studies that have shown that early mortality after ART initiation is related to the delayed treatment initiation due to late presentation to care (4, 24-26). Baseline CD4 cell counts ≤50 cells/µL was associated with early mortality in univariate analyses, however, it was not associated in multivariate models, probably because clinical staging was a better indicator of early death (26). "
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ABSTRACT: A retrospective study was conducted to determine the mortality, causes and risk factors for death among HIV-infected patients receiving antiretroviral therapy (ART) in Korea. The outcomes were determined by time periods, during the first year of ART and during 1-5 yr after ART initiation, respectively. Patients lost to follow-up were traced to ascertain survival status. Among 327 patients initiating ART during 1998-2006, 68 patients (20.8%) died during 5-yr follow-up periods. Mortality rate per 100 person-years was 8.69 (95% confidence interval, 5.68-12.73) during the first year of ART, which was higher than 4.13 (95% confidence interval, 2.98-5.59) during 1-5 yr after ART. Tuberculosis was the most common cause of death in both periods (30.8% within the first year of ART and 16.7% during 1-5 yr after ART). During the first year of ART, clinical category B and C at ART initiation, and underlying malignancy were significant risk factors for mortality. Between 1 and 5 yr after ART initiation, CD4 cell count ≤ 50 cells/µL at ART initiation, hepatitis B virus co-infection, and visit constancy ≤ 50% were significant risk factors for death. This suggests that different strategies to reduce mortality according to the time period after ART initiation are needed.
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