Braitstein P, Brinkhof MW, Dabis F, et al; Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration; ART Cohort Collaboration (ART-CC). Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries

The Lancet (Impact Factor: 45.22). 04/2006; 367(9513):817-24. DOI: 10.1016/S0140-6736(06)68337-2
Source: PubMed


Highly active antiretroviral therapy (HAART) is being scaled up in developing countries. We compared baseline characteristics and outcomes during the first year of HAART between HIV-1-infected patients in low-income and high-income settings.
18 HAART programmes in Africa, Asia, and South America (low-income settings) and 12 HIV cohort studies from Europe and North America (high-income settings) provided data for 4810 and 22,217, respectively, treatment-naïve adult patients starting HAART. All patients from high-income settings and 2725 (57%) patients from low-income settings were actively followed-up and included in survival analyses.
Compared with high-income countries, patients starting HAART in low-income settings had lower CD4 cell counts (median 108 cells per muL vs 234 cells per muL), were more likely to be female (51%vs 25%), and more likely to start treatment with a non-nucleoside reverse transcriptase inhibitor (NNRTI) (70%vs 23%). At 6 months, the median number of CD4 cells gained (106 cells per muL vs 103 cells per muL) and the percentage of patients reaching HIV-1 RNA levels lower than 500 copies/mL (76%vs 77%) were similar. Mortality was higher in low-income settings (124 deaths during 2236 person-years of follow-up) than in high-income settings (414 deaths during 20,532 person-years). The adjusted hazard ratio (HR) of mortality comparing low-income with high-income settings fell from 4.3 (95% CI 1.6-11.8) during the first month to 1.5 (0.7-3.0) during months 7-12. The provision of treatment free of charge in low-income settings was associated with lower mortality (adjusted HR 0.23; 95% CI 0.08-0.61).
Patients starting HAART in resource-poor settings have increased mortality rates in the first months on therapy, compared with those in developed countries. Timely diagnosis and assessment of treatment eligibility, coupled with free provision of HAART, might reduce this excess mortality.

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    • "As a result, home-based care (HBC) is increasingly being used as a key management strategy in many countries, especially where the public health services are already overburdened with limited human and financial resources. Mortality among HIV-infected individuals initiating ART in sub- Saharan Africa is higher than in industrialized countries [6]. In a retrospective study, the proportion of all hospital deaths attributed to HIV was reported to be 38.7% in the medical ward of a tertiary hospital in north-western Nigeria [7]. "
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    ABSTRACT: Aim To identify factors associated with home and hospital deaths among human immunodeficiency virus (HIV) infected adult patients in Nigeria. Background Causes of mortality among HIV infected hospitalized patients on anti-retroviral therapy (ART) have been characterized in sub-Saharan Africa. However, majority of deaths occur outside hospitals. Materials and methods We undertook a retrospective clinical review on patients who were on ART and died at home or in the hospital. We obtained additional information on those who died at home through verbal autopsy and qualitative interview by our Home Based Care Team (HBCT). Results A total of 101 patient deaths over three years were reviewed. Those who died at home (51) or hospital (50) had similar ages, gender, co-morbidities, proportions with stages III/IV disease and opportunistic diseases. The median pre-ART CD4 cell counts for those who died at home and hospital was 108 cells/μl and 72.0 cells/μl respectively and they had been on similar ART regimens. Adherence was less 14/51 (27.5%) versus 30/50 (60%) (p = 0.040) and use of traditional medicines (TM) higher 41/51 (80.4%) versus 16/50 (32%) (p = 0.014) among those who died at home. Tuberculosis (TB) was the commonest cause of death accounting for 33/51 (64.7%) and 31/50 (62.0%) (p = 0.979) of the home and hospital deaths respectively. Verbal autopsy and qualitative interview also identified TB, poor adherence, ART drug resistance and side effects as well as poverty, stigma, use of TM and spiritual alternatives as important causes of deaths. Tuberculosis is the overall cause of death. Conclusion Strategies for improving adherence, prevention and treatment of TB should be explored.
    Full-text · Article · Mar 2015 · HIV and AIDS Review
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    • "This could be taken as an indication that irrespective of the approach to HIV testing, those HIV-positive patients most in need of linkage to care were in fact prioritised by health providers for ART initiation, which is reassuring. The HIV immune status was similar across arms and in line with median CD4 levels reported in other LMIC and high-income countries [27–29] and this is perhaps indicative of the high risk status of STI patients in this setting [21, 30, 31]. "
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    ABSTRACT: BackgroundWe examined linkage to care for patients with sexually transmitted infection who were diagnosed HIV-positive via the provider-initiated HIV testing and counselling (PITC) approach, as compared to the voluntary counselling and testing (VCT) approach, as little is known about the impact of expanded testing strategies on linkage to care.MethodsIn a controlled trial on PITC (Cape Town, 2007), we compared HIV follow-up care for a nested cohort of 930 HIV-positive patients. We cross-referenced HIV testing and laboratory records to determine access to CD4 and viral load testing as primary outcomes. Secondary outcomes were HIV immune status and time taken to be linked to HIV care. Logistic regression was performed to analyse the difference between arms.ResultsThere was no difference in the main outcomes of patients with a record of CD4 testing (69.9% in the intervention, 65.2% in control sites, OR 0.82 (CI: 0.44-1.51; p = 0.526) and viral load testing (14.9% intervention versus 10.9% control arm; OR 0.69 (CI: 0.42-1.12; p = 0.131). In the intervention arm, ART-eligible patients (based on low CD4 test result), accessed viral load testing approximately 2.5 months sooner than those in the control arm (214 days vs. 288 days, HR: 0.417, 95% CI: 0.221-0.784; p = 0.007).ConclusionThe PITC intervention did not improve linkage to CD4 testing, but shortened the time to viral load testing for ART-eligible patients. Major gaps found in follow-up care across both arms, indicate the need for more effective linkage-to-HIV care strategies.Trial registrationCurrent Controlled Trials ISRCTN93692532Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-350) contains supplementary material, which is available to authorized users.
    Full-text · Article · Aug 2014 · BMC Health Services Research
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    • "This lack of knowledge regarding HIV status can increase the risk of transmission within the general population and may compromise the success of new prevention strategies, such as oral pre-exposure and post-exposure prophylaxis and microbicide gel. In addition, approximately 40% of new diagnoses are made during a late stage of infection when patients are already severely immunosuppressed [3], [4], leading to increased mortality [5]. "
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    ABSTRACT: BackgroundSeveral countries have recently recommended the expansion of anti-human immunodeficiency virus (HIV) antibody testing, including self-testing with rapid tests using oral fluid (OF). Several tests have been proposed for at-home use, but their diagnostic accuracy has not been fully evaluated.ObjectiveTo evaluate the performance of 5 rapid diagnostic tests for the detection of anti-HIV-1/2 antibodies, with 4 testing OF and 1 testing whole blood.MethodsProspective multi-center study in France. HIV-infected adults and HIV-uninfected controls were systematically screened with 5 at-home HIV tests using either OF or finger-stick blood (FSB) specimens. Four OF tests (OraQuick Advance Rapid HIV-1/2, Chembio DPP HIV 1/2 Assay, test A, and test B) and one FSB test (Chembio Sure Check HIV1/2 Assay) were performed by trained health workers and compared with laboratory tests.ResultsIn total, 179 HIV-infected patients (M/F sex ratio: 1.3) and 60 controls were included. Among the HIV-infected patients, 67.6% had an undetectable HIV viral load in their plasma due to antiretroviral therapy. Overall, the sensitivities of the OF tests were 87.2%, 88.3%, 58.9%, and 28% (for OraQuick, DPP, test A, and test B, respectively) compared with 100% for the FSB test Sure Check (p<0.0001 for all comparisons). The OraQuick and DPP OF tests' sensitivities were significantly lower than that of the FSB-based Sure Check (p<0.05). The sensitivities of the OF tests increased among the patients with a detectable HIV viral load (>50 copies/mL), reaching 94.8%, 96.5%, 90%, and 53.1% (for OraQuick, DPP, test A, and test B, respectively). The specificities of the four OF tests were 98.3%, 100%, 100%, and 87.5%, respectively, compared with 100% for the FSB test.ConclusionAn evaluation of candidates for HIV self-testing revealed unexpected differences in performance of the rapid tests: the FSB test showed a far greater reliability than OF tests.
    Full-text · Article · Jun 2014 · PLoS ONE
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