Predictors of early death in a cohort of Ethiopian patients treated with HAART

Survival-related factors in HIV/AIDS patients: A retrospective cohort study from 2011 to 2019 in Kermanshah, Iran

INTRODUCTION

Accurate evaluation of the survival rate among HIV-positive populations is pivotal for HIV management.

OBJECTIVE

This study aimed to investigate the survival rate and potential survival-related factors in HIV/AIDS patients from 2011 to 2019 in the city of Kermanshah in the west of Iran.

METHOD

In this study, 915 HIV-positive patients registered by the Kermanshah Behavioral diseases counseling center, were surveyed from 2011 to 2019. By reading the patients' files, the proper data related to the survival factors were extracted and statistically analyzed.

RESULTS

Of 915 patients, 220 (24%) died. The one-year, five-year, and ten-year survival rates were 84%, 72%, and 62%, respectively. There was a significant relationship between the survival rate and many other parameters, including treatment variables, CD4+ T cell count, the way of HIV transmission, level of education, gender, and marital status. Over time, timely initiation of treatment has increased. The data also showed that HIV transmission through drug injection has decreased, while the sexual transmission of HIV has increased.

CONCLUSIONS

The results showed that in recent years, due to the appropriate treatment, the survival rate of HIV patients has increased. The highest risk factor of death was for people with low CD4+ T cell count, lack of antiretroviral therapy, low level of education, male gender, and people who inject drugs. These people need more attention to get tested for HIV- related indexes and to receive proper treatment.

Predictors of mortality rate among adult HIV-positive patients on antiretroviral therapy in Metema Hospital, Northwest Ethiopia: a retrospective follow-up study

Background

Globally Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is an ongoing public health issue associated with high morbidity and mortality. Efforts have been made to reduce HIV/AIDS-related morbidity and mortality by delivering antiretroviral therapy. However, the incidence and predictors of mortality in border areas like Metema were not investigated. This study aimed to assess predictors of mortality rate among adult HIV-positive patients on antiretroviral therapy at Metema Hospital.

Methods

Retrospective follow-up study was employed among ART patients from January 1, 2013, to December 30, 2018. Data were entered in Epi-data 3.1 and exported to STATA 14 for analysis. Kaplan–Meier and Log-Rank test was used to compare survival differences among categories of different variables. In bi-variable analysis p-values < 0.20 were entered into a multivariable analysis. Multivariate Weibull model was used to measure the risk of death and identify the significant predictors of death. Variables that were statistically significant at p-value < 0.05 were concluded as predictors of mortality.

Result

A total of 542 study participants were included. The overall incidence rate was 6.7 (95% CI: 5.4–8.4) deaths per 100 person-years of observation. Being male (HR = 2.4; 95% CI: 1.24–4.62), STAGE IV (HR = 5.64; 95% CI: 2.53–12.56), stage III (HR = 3.31; 95% CI: 1.35–8.10), TB-coinfection (HR = 3.71; 95% CI: 1.59–8.64), low hemoglobin (HR = 4.14; 95% CI: 2.18–7.86), BMI ≤ 15.4 kg/m² (HR = 2.45; 95% CI: 1.17–5.10) and viral load > 1000 copy/ml (HR = 6.70; 95% CI: 3.4–13.22) were found to be a significant predictor for mortality among HIV patients on ART treatment.

Conclusion

The incidence of death was high. Being male, viral load, those with advanced STAGE (III & IV), TB co-infected, low BMI, and low hemoglobin were at a higher risk of mortality. Special attention should be given to male patients and high public interventions needed among HIV patients on ART to reduce the mortality rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00353-z.

Survival and Predictors of Mortality Among HIV Positive Adult Patients on Highly Active Antiretroviral Therapy in Public Hospitals of Kambata Tambaro Zone, Southern Ethiopia: A Retrospective Cohort Study

Background

Human Immune Deficiency Virus (HIV) infection remains the leading cause of morbidity and mortality. In Ethiopia, despite test and treat all HIV positives are adopted, a significant number of people eligible for Anti-Retroviral Therapy (ART) show up with advanced disease and at lower CD4 count. There is currently paucity of studies conducted that investigate predictors of mortality among adults on ART in the study area.

Objective

To explore Survival and predictors of mortality among adult HIV-positive patients on ART in Kambata Tambaro Zone, Ethiopia, from August 2013 to February 2019.

Methods

A health facility-based retrospective cohort study was conducted among records of 467 adult HIV-positive patients on ART selected using simple random sampling. Data were collected using standardized abstraction tool. Kaplan–Meier, Log rank tests and Cox regression model was applied to estimate survival status and identify predictors of mortality, respectively.

Results

Of the total 467 study subjects, 59 (12.63%) of them died in the study period. The median follow-up time of the cohort was 40.1 (IQR=13.6–59.0) months. The mortality rate of the cohort was 4.1 per 100 PYO. The overall survival probability of the cohort was 84.38% (95 CI=80.08–87.82) at 66 months. Bedridden function AHR=3.0 (95% CI, 1.44–6.64), Fair-adherence AHR=3.3 (95% CI, 1.50–7.07), Poor-adherence AHR=3.8 (95% CI, 1.88–7.96), presence of OIs AHR=4.2 (95% CI, 1.98–8.50), Late diagnosis (CD4 count >/=350) AHR=3.0 (95% CI, 1.91–6.42) and Immunologic failure AHR=3.5 (95% CI, 1.41–6.29) were independent predictors of time to death in Cox-Regression.

Conclusion

Late Diagnosis, poor adherence, being bedridden, having OI and Immunologic failure were independently associated with time to death. Early diagnosis to start treatment and emphasizing on close follow-up care to improve treatment adherence should be given special emphasis.

Effects of undernutrition on mortality and morbidity among adults living with HIV in sub-Saharan Africa: a systematic review and meta-analysis

Background

Undernutrition is one of the most common problems among people living with HIV, contributing to premature death and the development of comorbidities within this population. In Sub-Saharan Africa (SSA), the impacts of these often inter-related conditions appear in a series of fragmented and inconclusive studies. Thus, this review examines the pooled effects of undernutrition on mortality and morbidities among adults living with HIV in SSA.

Methods

A systematic literature search was conducted from PubMed, EMBASE, CINAHL, and Scopus databases. All observational studies reporting the effects of undernutrition on mortality and morbidity among adults living with HIV in SSA were included. Heterogeneity between the included studies was assessed using the Cochrane Q-test and I² statistics. Publication bias was assessed using Egger’s and Begg’s tests at a 5% significance level. Finally, a random-effects meta-analysis model was employed to estimate the overall adjusted hazard ratio.

Results

Of 4309 identified studies, 53 articles met the inclusion criteria and were included in this review. Of these, 40 studies were available for the meta-analysis. A meta-analysis of 23 cohort studies indicated that undernutrition significantly (AHR: 2.1, 95% CI: 1.8, 2.4) increased the risk of mortality among adults living with HIV, while severely undernourished adults living with HIV were at higher risk of death (AHR: 2.3, 95% CI: 1.9, 2.8) as compared to mildly undernourished adults living with HIV. Furthermore, the pooled estimates of ten cohort studies revealed that undernutrition significantly increased the risk of developing tuberculosis (AHR: 2.1, 95% CI: 1.6, 2.7) among adults living with HIV.

Conclusion

This review found that undernutrition has significant effects on mortality and morbidity among adults living with HIV. As the degree of undernutrition became more severe, mortality rate also increased. Therefore, findings from this review may be used to update the nutritional guidelines used for the management of PLHIV by different stakeholders, especially in limited-resource settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05706-z.

Epidemiology of survival pattern and its predictors among HIV positive patients on highly active antiretroviral therapy in Southern Ethiopia public health facilities: a retrospective cohort study

BACKGROUND

In resource poor countries like Ethiopia, little is known about the survival of patients treated with antiretroviral therapy which depends on different factors. Evidence shows that mortality has been high particularly in the first 3 to 6 months of initiating antiretroviral therapy. Hence, the study aimed to assess the Epidemiology of survival pattern and its determinants among adult HIV positive patients on highly active antiretroviral therapy.

METHODS

Retrospective cohort study was employed among a total of 455 records of patients who were enrolled on antiretroviral therapy from September 2006 to August 2010. Socio-demographic, clinical, immunological, behavioral, and date of antiretroviral treatment initiation including date of follow up status were extracted. Significant predictor variables were identified by fitting Cox's proportional hazard model using a backward stepwise method and statistical significance variables were declared based on a p-value less than 0.05.

RESULTS

A total of 455 adult HIV/AIDS patients on ART contributed to 886.05-person-year of observation and 65.7% were alive and on treatment, 17.1% were lost to follow up and 7.5% died. The study showed that the estimated mortality was 4.4%, 5.3%, 6.1%, 7%, 7.5% and 7.5% at 6, 12, 24, 36, 48 and 60 months of follow up period, respectively. The overall incidence rate of mortality was 4.2 per 100 person-years of observation. In multivariate analysis age 45 and above (AHR: 3.72, 95% CI 1.21-11.4), bedridden functional status (AHR: 17.4, 95% CI 6.21-48.79), poor ART drug adherence (AHR: 4.52,95% CI 2.05-9.96), Tuberculosis co-infection (AHR: 4.1, 95% CI 1.84-9.13), non-disclosure (AHR: 4.9, 95% CI 1.82-12.89) and severe anemia (AHR: 5.1, 95% CI 1.81-14.21) were found predictors.

CONCLUSION

Patients with older age, tuberculosis infection, bedridden patients and severe anemia were predictors. Tracing poorly adhered patients and giving drug counseling as well as encouraging them for disclosure to their families is crucial to improve their survival.

Adolescents living with HIV are at higher risk of death and loss to follow up from care: Analysis of cohort data from eight health facilities in Ethiopia

Background

There are limited data on the treatment outcomes of adolescents living with HIV. Our objective was to compare mortality and loss to follow up (LTFU) rates between adolescent and younger age groups at enrollment in care.

Methods

This was a retrospective cohort study carried out in eight health facilities in two regions of Ethiopia. Adolescents (age 10–14 and 15–19 year) and children (age 0–9 year) enrolled in chronic HIV care between 2005 and 2013 constituted the study population. We reviewed the individual patient charts between March and June 2014 and updated the data on the status of each patient through December 2015. We used death and loss-to-follow up as primary endpoints and used the Cox-regression analysis where age, categorized as adolescent versus child, was the main predictor variable.

Results

Of 2058 participants studied, 52.1% were adolescents. The cohort contributed 2422 person-years of observation (PYO) during the pre-ART follow-up, whereas 1531 patients put on ART contributed 5984 PYO. Of those put on ART, 209 (13.7%) LTFU and 92 (6%) deaths were reported. Adolescents in age group 15–19 yr had the highest risk of LTFU [adjusted hazard ratio, aHR (95% CI) = 3.1 2.1, 5.0 ] followed by those in age group 10–14 yr (aHR = 1.5 [0.9, 2.3]) compared with children aged 0–9 yr. Mortality hazard was significantly higher among younger adolescents (aHR = 2.8 [1.4, 5.4]) and older adolescents (aHR = 2.3 [1.1, 4.9]) compared with children.

Conclusions

Adolescents are at higher risk of mortality and LTFU as compared to children ages 0–9. Younger adolescents and children had similar LTFU rates. Narrow age band disaggregated analysis can serve as useful guide for tailoring interventions to the specific needs of different age groups.

Predictors of mortality in adult people living with HIV on antiretroviral therapy in Nepal: A retrospective cohort study, 2004-2013

Background

In Nepal, since 2004, 19,388 people living with HIV (PLHIV) have been enrolled on antiretroviral therapy (ART). The aim of this study was to measure mortality rate and to identify predictors of mortality in adult (≥15 years) PLHIV who initiated ART between 2004 and 2013 in five large ART centers of Nepal.

Methods

This retrospective cohort study of 3,799 (60.5% male) adult PLHIV uses secondary data collected from standard ART registers. Time from ART initiation (baseline) to death or censoring (loss to follow-up or December 31, 2013) was assessed. Mortality rates per 100 person-years were calculated. Kaplan-Meier models were used to estimate the probability of mortality over time. Predictors of mortality were determined using Cox-regression models.

Results

The overall mortality rate was 6.98 (95% CI: 6.46–7.54) per 100 person-years, 4.11 (95% CI: 3.53–4.79) in females and 9.14 (95% CI: 8.36–9.99) in males. Mortality rates were higher in early months after ART initiation, particularly in the first three months. Baseline predictors of mortality were ART center, male gender (adjusted HR = 2.08, 95% CI: 1.69–2.57), residence outside the ART district (AHR = 1.45, 95% CI:1.19–1.76), World Health Organization clinical stage III (AHR = 1.67, 95% CI: 1.13–2.46) and IV (AHR = 2.21, 95% CI: 1.45–3.36), bedridden <50% time in the last month (AHR = 1.92, 95% CI: 1.52–2.41), bedridden >50% time in the last month (AHR = 3.82, 95% CI: 2.95–4.94), lower bodyweight/kg (AHR = 1.04, 95% CI: 1.03–1.05), CD4 count <150 cell/mm³ (AHR = 2.14, 95% CI: 1.05–4.34) and treatment not switched to second-line regimen (AHR = 3.05, 95% CI: 1.35–6.90).

Conclusions

Mortality rates were higher soon after ART initiation, particularly in males and gradually decreased over time. Poor baseline clinical characteristics were significantly associated with higher mortality. Increased ART coverage with decentralization of sites to lower levels including community dispensing, differentiated and improved service delivery and initiation of ART at a less advanced disease stage may reduce early mortality.

Predictors of Survival among Adult Ethiopian Patients in the National ART Program at Seven University Teaching Hospitals: A Prospective Cohort Study

Background

In Ethiopia, the publicly funded antiretroviral treatment (ART) program was started in 2005. Two hundred seventy-five thousand patients were enrolled in the national ART program by 2012. However, there is limited data on mortality and predictors of death among adult patients in the ART program. The study aimed to estimate mortality and risk factors for death among adult, ART-naïve patients, started in the national ART program from January 2009 to July 2013.

Methods

Multi-site, prospective, observational cohort study of adult, age > 18 years, ART-naïve patients, started in the national ART program at seven university-affiliated hospitals from January 2009 – July 2013. Kaplan-Meier and Cox regression analyses were used to estimate survival and determine risk factors for death.

Results

A total of 976 patients, 594 females (60.9 %), were enrolled into the study. Median age of the cohort was 33years. The median CD4 count at start of ART was 144 cells/µl (interquartile range (IQR) 78–205), and 34.2% (330/965) had CD4 < 100. Sixty-three percent (536/851) had viral load greater than 5 log copies/ml (IQR 4.7–5.7) at base line. One hundred and one deaths were recorded during follow-up period, all-cause mortality rate 10.3%; 5.4 deaths/100 person years of observation, 95% confidence interval 4.4–6.5. Seventy percent of the deaths occurred within six months of starting ART. Cox regression analyses showed that the following measures independently predicted mortality: age >51 years, (Adjusted Hazard Ratio (AHR) 4.01, P=0.003), WHO stages III&IV, (AHR 1.76, p = 0.025), CD4 count, <100, (AHR 2.36, p =0.006), and viral load >5 log copies /ml (CHR 1.71, p = 0.037).

Conclusion

There is high early on- ART mortality in patients presenting with advanced immunodeficiency. Detecting cases and initiating ART before onset of advanced immunodeficiency might improve survival.

Comparison of treatment adherence outcome among PLHIV enrolled in economic strengthening program with community control

Economic strengthening (ES) interventions are increasingly promoted to support the economic well-being and food security of people living with HIV (PLHIV) in resource poor settings. This study aims to assess the impact of ES interventions in Ethiopia designed to address poverty and food insecurity on antiretroviral treatment (ART) adherence. A comparative cross-sectional design was employed to compare treatment adherence between food insecure PLHIV benefitting from the ES project of WFP Ethiopia to food insecure PLHIV not participating in ES. Using the visual analogue scale (VAS) to measure ART adherence, only 9.9% of the ES group reported less than 95% adherence compared to 25.9% of the comparison group. Controlling for socio-economic and demographic variables using logistic regression models, engagement in ES activities increased the likelihood of having 95% or greater ART adherence by a factor of 2.4 and 5.6 respectively (as measured by VAS and ACTG approaches) compared to those PLHIV that were not engaged in ES. The findings of the study suggest that engagement in ES contributes to improved ART adherence among food insecure PLHIV. If further studies validate this result, ES should be adopted as a key strategy to improve HIV treatment adherence in resource poor settings where adherence is an issue of concern.

Prevalence and Risk Factors of Mortality among Adult HIV Patients Initiating ART in Rural Setting of HIV Care and Treatment Services in North Western Tanzania: A Retrospective Cohort Study

Introduction

HIV still causes high mortality despite use of ART. This study was designed to determine the prevalence and risk factors of mortality among HIV patients receiving ART in northwestern rural Tanzania.

Methods

A retrospective study of HIV patients on ART was done at Sengerema in Mwanza, Tanzania. The data on demography, date of HIV diagnosis, WHO stage, opportunistic infections, CD4, hemoglobin, ART regimen, and time and outcome on treatment as dead or alive were collected and analyzed using STATA version 11.

Results

In total, 740 patients were studied. The median age was 35 (27–42) years with female predominance of 465 (62.8%). Of the participants, 261 (35.3%) had WHO stages 3 and 4 diseases. Most participants, 258 (34.9%), had baseline CD4 counts <200 cells/μl. Deaths occurred in 86 (11.6%) patients which were independently associated with male gender (16.0% versus 9.0%, p = 0.015), being divorced (OR = 2.7, p < 0.001), WHO stages 3 and 4 (OR = 2.3, p = 0.05), CD4 <200 cells/μl (OR = 3.4, p < 0.001), and severe anemia (OR = 6.6, p < 0.001).

Conclusions

The mortality is high among HIV patients receiving ART in northwestern rural Tanzania. Universal testing could increase early diagnosis and treatment. A close follow-up of at-risk patients within the first year of ART could reduce the mortality of this subgroup of patients.

Effects of Antiretroviral Therapy on the Survival of Human Immunodeficiency Virus-positive Adult Patients in Andhra Pradesh, India: A Retrospective Cohort Study, 2007-2013

OBJECTIVES

The survival outcomes of antiretroviral treatment (ART) programs have not been systematically evaluated at the state level in India. This retrospective study assessed the survival rates and factors associated with survival among adult human immunodeficiency virus (HIV)-infected patients in Andhra Pradesh, India.

METHODS

The present study used data from 139 679 HIV patients aged ≥15 years on ART who were registered from 2007 to 2011 and were followed up through December 2013. The primary end point was death of the patient. Mortality densities (per 1000 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore the factors associated with survival.

RESULTS

The overall median follow-up time was 16.0 months (2.0 months for the deceased and 14.0 months for those lost to follow-up). Approximately 13.2% of those newly initiated on ART died during follow-up. Of those deaths, 56% occurred in the first three months. The crude mortality rate was 80.9 per 1000 person-years at risk. The CD4 count (adjusted hazard ratio [aHR],4.88; 95% confidence interval [CI], 4.36 to 5.46 for <100 cells/mm3 vs. >350 cells/mm3), functional status (aHR, 3.05; 95% CI, 2.82 to 3.30 for bedridden vs. normal), and body weight (aHR, 3.69; 95% CI, 3.42 to 3.97 for <45 kg vs. >60 kg) were strongly associated with the survival of HIV patients.

CONCLUSIONS

The study findings revealed that high mortality was observed within the first three months of ART initiation. Patients with poor baseline clinical characteristics had a higher risk of mortality. Expanded testing and counseling should be encouraged, with the goal of ensuring early enrollment into the program followed by the initiation of ART in HIV-infected patients.

Nutritional status and its effect on treatment outcome among HIV infected clients receiving HAART in Ethiopia: a cohort study

Purposes

The aim of this study was to determine the effects of nutritional status at the start of highly active anti-retroviral therapy on treatment outcomes among HIV/AIDS patients taking HAART at Jimma University Specialized Hospital.

Methods

We performed a retrospective cohort study involving 340 adults who started highly active anti-retroviral therapy. The patients have been clinically followed for 2 years. Data were extracted from paper based medical charts by trained data collectors from January 30 to February 28, 2014 using data collection format. We entered data into Epi data version 3.1 and then exported to SPSS for windows version 21. Predictors of CD4 change were identified using multivariable linear regression model. Time to an event (death) was estimated by Kaplan–Meier and predictors of mortality were identified by Cox proportional hazard model.

Results

Out of 340 patients, 42 patients died during the follow-up. Twenty-five (59.5 %) deaths were from malnourished group. Age, baseline CD4, sex, baseline HAART and marital status were significant predictors of immunologic recovery at different time points. Malnutrition was associated with lower CD4 recovery and greater hazard of death.

Conclusions

Malnutrition tends to decrease CD4 recovery and predisposes patient to early death.

Correlates of Strengthening Lessons from HIV/AIDS Treatment and Care Services in Ethiopia Perceived Access and Implications for Health System

BACKGROUND

Access to healthcare is an important public health concept and has been traditionally measured by using population level parameters, such as availability, distribution and proximity of the health facilities in relation to the population. However, client based factors such as their expectations, experiences and perceptions which impact their evaluations of health care access were not well studied and integrated into health policy frameworks and implementation programs.

OBJECTIVE

This study aimed to investigate factors associated with perceived access to HIV/AIDS Treatment and care services in Wolaita Zone, Ethiopia.

METHODS

A cross-sectional survey was conducted on 492 people living with HIV, with 411 using ART and 81 using pre-ART services accessed at six public sector health facilities from November 2014 to March 2015. Data were analyzed using the ologit function of STATA. The variables explored consisted of socio-demographic and health characteristics, type of health facility, type of care, distance, waiting time, healthcare responsiveness, transportation convenience, satisfaction with service, quality of care, financial fairness, out of pocket expenses and HIV disclosure.

RESULTS

Of the 492 participants, 294 (59.8%) were females and 198 (40.2%) were males, with a mean age of 38.8 years. 23.0% and 12.2% believed they had 'good' or 'very good' access respectively, and 64.8% indicated lower ratings. In the multivariate analysis, distance from the health facility, type of care, HIV clinical stage, out of pocket expenses, employment status, type of care, HIV disclosure and perceived transportation score were not associated with the perceived access (PA). With a unit increment in satisfaction, perceived quality of care, health system responsiveness, transportation convenience and perceived financial fairness scores, the odds of providing higher rating of PA increased by 29.0% (p<0.001), 6.0%(p<0.01), 100.0% (p<0.001), 9.0% (p<0.05) and 6.0% (p<0.05) respectively.

CONCLUSION

Perceived quality of care, health system responsiveness, perceived financial fairness, transportation convenience and satisfaction with services were correlates of perceived access and affected healthcare performance. Interventions targeted at improving access to HIV/AIDS treatment and care services should address these factors. Further studies may be needed to confirm the findings.

Brief Report: Long-term Outcomes and Their Determinants in Patients on Antiretroviral Treatment in Ethiopia, 2005/6-2011/12: A Retrospective Cohort Study

BACKGROUND

Antiretroviral treatment (ART) programs in many resource-limited settings have expanded treatment toward universal access. Ethiopia is one of the countries that has been scaling up ART toward universal access, but with very few data on long-term outcomes and their determinants. The objective of this study was to identify the level of long-term outcomes and their determinants in patients on ART in Ethiopia.

METHODS

A retrospective cohort study was conducted in 3 health facilities (2 hospitals and 1 health center) between July and September, 2014. Loss to follow-up, death, attrition, and retention were the primary outcomes. Data were collected from patient registers and medical records for the period 2005/6-2011/12.

RESULTS

A total of 11,731 patients were included in the study. The overall retention rate was 78 per 100 person-months. Retention rates were 82%, 74%, and 72% at 24, 60, and 84 months on ART, respectively. Retention was associated with male sex, adolescent age, marital status, advanced HIV disease, illiteracy, and peer-support services; however, long-term retention was associated independently with only male sex [with adjusted hazard ratio (aHR) 0.68 (0.56 to 0.77)], married patients [with aHR 0.62 (0.54 to 0.72)], and peer-support services [with aHR 1.62 (1.58 to 1.66)].

DISCUSSION AND CONCLUSIONS

ART programs have lost most of their patients during the first 24 months on ART. It is, therefore, imperative that HIV/ART programs ensure people are tested, linked to care, and initiated on ART early. ART programs should also design and implement interventions, including peer-support services, which are targeted to male, adolescent, unmarried, and illiterate patients.

Early Versus Delayed Mortality among HIV Infected Patients Initiating Highly Active Antiretroviral Therapy in Tanzania

Development of HAART in the mid-1990's and its continued scale up has revolutionized the treatment of HIV-infected patients and led to remarkable reductions in HIV associated morbidity and mortality. However, recent studies have suggested a higher risk for early mortality in adults receiving ART in low-income countries as compared to those in high-income countries. There is dearth of data from developing countries where the burden of disease is high. The objective is to describe the burden and correlation between early vs. delayed mortality associated with HIV/AIDS in resource poor settings using data from Tanzania in East Africa. We performed a cross-sectional evaluation of routinely collected program data for 991 HIV-positive deceased adult patients who were placed on ART treatment, and died between January 1, 2007 and December 31, 2012. Data used were abstracted from records of patients who were treated at six health facilities in the Lake-zone Region of Tanzania in the timeframe. Bivariate and multivariate regression models were used to identify independent predictors of mortality and to calculate odds ratios. From the population, early deaths (within 3 months of ART initiation) occurred in 359 of the 991 cases, which represented 36.2%; while delayed deaths (after 3 months of ART initiation) occurred in 632 of 991 (63.8%). The average time to death for those who died within 3 months was 1 month compared to 22 months among those who died at > 3 months since initiation of ARV. In multivariate analysis, patients who were on WHO stage IV, had fever and cough symptoms at 6 months prior to death and patients with 0-1, 2-3, and 4-6 clinic visits had a higher risk of death in the first 3 months. Mortality among patients started on ART seems to be high. Where possible, healthcare providers should do more to vigorously monitor patients before starting them on ART for better outcomes. Additionally, public health efforts to encourage early testing and entry into treatment must be scaled up in resource poor countries to gain some lead-time and to keep the virus under control, sustain immune function, and delay the onset of opportunistic infections.

Survival and determinants of mortality in adult HIV/Aids patients initiating antiretroviral therapy in Somali Region, Eastern Ethiopia

INTRODUCTION

Studies have shown high initial mortality in Antiretroviral Therapy (ART) programs from resource-limited settings. However, there is dearth of evidence on treatment outcomes and associated determinant factors in public hospitals. Therefore, the objective of this study is to assess survival and identify predictors of death in adult HIV-infected patients initiating ART at a public hospital in Eastern Ethiopia.

METHODS

A retrospective cohort study was conducted by reviewing baseline and follow-up records of patients who started ART between December 1, 2007 and December 31, 2011 at Kharamara hospital. Time to death was the main outcome measure. Kaplan-Meier models were used to estimate mortality and Cox proportional hazards models to identify predictors of mortality.

RESULTS

A total of 784 patients (58.4% females) were followed for a median of 60 months. There were 87 (11.1%) deaths yielding an overall mortality rate of 5.15/100 PYO (95% CI: 4.73-6.37). The estimated mortality was 8.4%, 9.8%, 11.3%, 12.7% and 14.1% at 6, 12, 24, 36 and 48 months respectively. The independent predictors of death were single marital status (AHR: 2.31; 95%CI: 1.18-4.50), a bedridden functional status (AHR: 5.91; 95%CI: 2.87-12.16), advanced WHO stage (AHR: 7.36; 95%CI: 3.17-17.12), BMI < 18.5 Kg/m2 (AHR: 2.20; 95%CI: 1.18-4.09), CD4 count < 50 cells/µL (AHR: 2.70; 95%CI: 1.26-5.80), severe anemia (AHR: 4.57; 95%CI: 2.30-9.10), and TB co-infection (AHR: 2.30; 95%CI: 1.28-4.11).

CONCLUSION

Improved survival was observed in patients taking ART in Somali region of Ethiopia. The risk for death was higher in patients with advanced WHO stage, low CD4 count, low Hgb, low BMI, and concomitant TB infection. Intensive case management is recommended for patients with the prognostic factors. Optimal immunologic and weight recoveries in the first 6 months suggest increased effort to retain patients in care at this period.

Effects of highly active antiretroviral therapy on the survival of HIV-infected adult patients in urban slums of Kenya

Recent improvements in access to Anti-Retroviral Therapy (ART) have radically reduced hospitalizations and deaths associated with HIV infection in both developed countries and sub-Saharan Africa. Not much is known about survival of patients on ART in slums. The objective of this study was to identify factors associated with mortality among adult patients on ART in resource poor, urban, sub-Saharan African setting. A prospective open cohort study was conducted with adult patients on ART at a clinic in Kibera slums, Nairobi, Kenya. The patients' enrollment to care was between March 2005 and November 2011. Descriptive statistics were computed and Kaplan-Meier (KM) methods used to estimate survival time while Cox's proportional hazards (CPH) model fitted to determine mortality predictors. A total of 2,011 adult patients were studied, 69% being female. Female gender (p=0.0016), zidovudine-based regimen patients (p<0.0001), CD4 count>351 patients (p<0.0001), WHO stage I patients (p<0.0001) and "Working" functional status patients recorded better survival probability on ART. In CPH analysis, the hazard of dying was higher in patients on Stavudine-based regimen(hazard ratio (HR)=.8; 95% CI, 1.5-2.2; p<0.0001),CD4 count<50 cells/µl (HR=1.6; 95% CI, 1.5-1.7;p<0.0001), WHO Stage IV at ART initiation (HR=1.3; 95% CI, 1.1-1.6; p=0.016) and bedridden patients (HR=2.7; 95% CI, 1.7-4.4;p<0.0001). There was increased mortality among the males, those with advanced Immunosuppression, late WHO stage and bedridden patients. The findings further justify the need to switch patients on Stavudine-based regimen as per the WHO recommendations.

Characteristics and predictors of death among hospitalized HIV-infected patients in a low HIV prevalence country: Bangladesh

BACKGROUND

Predictors of death in hospitalized HIV-infected patients have not been previously reported in Bangladesh.

OBJECTIVE

The primary aim of this study was to determine predictors of death among hospitalized HIV-infected patients at a large urban hospital in Bangladesh.

METHODS

A study was conducted in the HIV in-patient unit (Jagori Ward) of icddr,b's Dhaka Hospital. Characteristics of patients who died during hospitalization were compared to those of patients discharged from the ward. Bivariate analysis was performed to determine associations between potential risk factors and death. Multivariable logistic regression was used to identify factors independently associated with death.

RESULTS

Of 293 patients admitted to the Jagori Ward, 57 died during hospitalization. Most hospitalized patients (67%) were male and the median age was 35 (interquartile range: 2-65) years. Overall, 153 (52%) patients were diagnosed with HIV within 6 months of hospitalization. The most common presumptive opportunistic infections (OIs) identified were tuberculosis (32%), oesophageal candidiasis (9%), Pneumocystis jirovecii pneumonia (PJP) (8%), and histoplasmosis (7%). On multivariable analysis, independent predictors of mortality were CD4 count ≤200 cells/mm3 (adjusted odds ratio [aOR]: 16.6, 95% confidence interval [CI]: 3.7-74.4), PJP (aOR: 18.5, 95% CI: 4.68-73.3), oesophageal candidiasis (aOR: 27.5, 95% CI: 5.5-136.9), malignancy (aOR:15.2, 95% CI: 2.3-99.4), and bacteriuria (aOR:7.9, 95% CI: 1.2-50.5). Being on antiretroviral therapy prior to hospitalization (aOR: 0.2, 95% CI: 0.06-0.5) was associated with decreased mortality.

CONCLUSION

This study showed that most patients who died during hospitalization on the Jagori Ward had HIV-related illnesses which could have been averted with earlier diagnosis of HIV and proper management of OIs. It is prudent to develop a national HIV screening programme to facilitate early identification of HIV.

High-nutrition biscuits to increase animal protein in diets of HIV-infected Kenyan women and their children: a study in progress

BACKGROUND

Preliminary evidence suggests that improved nutrition early in HIV infection may delay progression to AIDS and delay the initiation or improve the effectiveness of antiretroviral drug therapy. There are few studies that evaluate food-based interventions in drug-naïve, HIV-infected women and their children. Meat provides several nutrients identified as important in maintaining immune function and lean body mass.

OBJECTIVE

To design supplemental meat and soybean biscuits for use in a randomized trial examining the effect of meat in the diet of drug-naïve, HIV-infected rural Kenyan women on changes in weight, lean body mass, morbidity, nutritional status, and activities of daily living of the women and growth and development of their children.

METHODS

We designed three supplemental biscuits: one with added dried beef another with added soybean flour, and a wheat biscuit to serve as a control biscuit to be used in a randomized feeding intervention in drug-naïve, HIV-infected rural Kenyan women and their children. The nutritional contents of the different types of biscuit were examined and compared.

RESULTS

The three biscuits were isocaloric. Meat biscuits provided more lysine, vitamin B12, and bioavailable zinc. Soybean biscuits provided more total and absorbable iron; however, higher fiber and phytate contents may inhibit nutrient absorption. Data analysis for clinical outcomes of the trial is ongoing.

CONCLUSIONS

The "biscuit model" is useful for nutrition supplementation studies because it can be provided in a blinded and randomized fashion, safely and privately in a home under directly observed consumption by a highly stigmatized population. It is well received by adults and children, and the biscuits can be produced locally with available, simple, affordable technology.

Factors associated with mortality in HIV-infected people in rural and urban South Africa

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.

Effects of nutrition counseling and monitoring on the weight and hemoglobin of patients receiving antiretroviral therapy in Ebonyi State, Southeast Nigeria

Introduction

The relationship between human immunodeficiency virus (HIV) and malnutrition is easily explained, and the etiology of malnutrition in HIV disease is believed to be multifactorial.

It therefore follows that ongoing assessment of nutritional and medical status is crucial to quality nutrition care for every person living with HIV. The aim of this study was to find out the effect of nutritional counseling and monitoring, using personalized dietary prescriptions, on the body mass index (BMI) and hemoglobin of patients who are HIV-infected and also receiving highly active antiretroviral drugs.

Methods

A total of 84 patients were selected using simple random sampling and allocated into intervention and control groups. Nutritional counseling and monitoring was done for the intervention group, while only weight, height, and hemoglobin concentration were monitored for the control group. At the end of 6 months, the differences in mean body mass index (BMI) and hemoglobin concentrations of the intervention and control groups were compared using the Student’s t-test. Statistical level of significance was put at P<0.05.

Results

Among respondents, 30.96% were males and 69.04% were females, and the mean age of the intervention group was 33.8 years and was 35.3 in the control group. After 6 months of study, the difference in the mean BMI among the males of both groups (24.9 kg/m² [intervention] and 24.3 kg/m² [control]) was not significant (P=0.53) but was significant among the females (24.9 kg/m² [intervention group] versus 21.8 kg/m² [control group]) (P=0.0005). The difference in mean hemoglobin concentration between the intervention and control groups for both males and females were statistically significant (12.2 mg/dL for males in the intervention group and 11.0 mg/dL for males in the control group [P=0.005]; 11.9 mg/dL for females in the intervention group and 11.0 mg/dL for females in the control group [P=0.010

Conclusion

Nutrition intervention is important in the management of people living with HIV/acquired immunodeficiency disease (AIDS) while on antiretroviral therapy. This can be achieved through nutritional counseling and monitoring.

Survival on antiretroviral treatment among adult HIV-infected patients in Nepal: a retrospective cohort study in Far-western region, 2006-2011

Background

Though financial and policy level efforts are made to expand antiretroviral treatment (ART) service free of cost, survival outcome of ART program has not been systematically evaluated in Nepal. This study assesses the mortality rates and determinants among adult HIV-infected patients on ART in Far-western region of Nepal.

Methods

This retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15^th 2006 and May 15^th 2011 in five ART sites in the Far-western region, Nepal. Follow-up time was calculated from the date of ART initiation to date of death or censoring (loss to follow-up, transferred out, or 15 November 2011). Mortality rates (per 100 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore determinants of mortality.

Results

The median follow-up time was 19.1 months. The crude mortality rate was 6.3 (95% confidence interval (CI) 5.3-7.6) but more than three-times higher in first 3 months after ART initiation (21.9 (95% CI 16.6- 28.8)). About 12% (83% men) of those newly initiated on ART died during follow-up. The independent determinants of mortality were male sex (hazard ratio (HR) 4.55, 95% CI 2.43-8.51), poor baseline performance scale (bedridden <50% of the day during the past month, HR 2.05, 95% CI 1.19-3.52; bedridden >50% of the day during the past month, HR 3.41, 95% CI 1.67-6.98 compared to normal activity), one standard deviation decrease in baseline bodyweight (HR 1.04, 95% CI 1.01-1.07), and poor WHO clinical stage (stage III, HR 2.96, 95% CI 1.31-6.69; stage IV, HR 3.28, 95% CI 1.30-8.29 compared to WHO clinical stage I or II).

Conclusions

High mortality was observed within the first 3 months of ART initiation. Patients with poor baseline clinical characteristics had higher mortality, especially men. Earlier initiation of ART through expanded testing and counselling should be encouraged in HIV-infected patients.

High Initial HIV/AIDS-Related Mortality and -Its Predictors among Patients on Antiretroviral Therapy in the Kagera Region of Tanzania: A Five-Year Retrospective Cohort Study

We examined mortality rates and its predictors from a five years retrospective cohort data of HIV/AIDs patients attending care and treatment clinic in Biharamulo Tanzania. Cox regression analysis was used to identify predictors of mortality. Of the 546 patient records retrieved, the mean age was 37 years with median CD4 count of 156 cells. The mortality rate was 4.32/100 person years at risk with males having three times higher mortality compared to females. Starting Antiretroviral treatment with advanced disease state, body weight below 45 kegs, WHO stage 4 disease, and CD4 cells below 50 were main predictors of mortality. Promoting early voluntary counselling and testing should be given a priority to facilitate timely start of treatment.

High loss to followup and early mortality create substantial reduction in patient retention at antiretroviral treatment program in north-west ethiopia

Background. There has been a rapid scale up of antiretroviral therapy (ART) in Ethiopia since 2005. We aimed to evaluate mortality, loss to followup, and retention in care at HIV Clinic, University of Gondar Hospital, north-west Ethiopia. Method. A retrospective patient chart record analysis was performed on adult AIDS patients enrolled in the treatment program starting from 1 March 2005. We performed survival analysis to determine, mortality, loss to followup and retention in care. Results. A total of 3012 AIDS patients were enrolled in the ART Program between March 2005 and August 2010. At the end of the 66 months of the program initiation, 61.4% of the patients were retained on treatment, 10.4% died, and 31.4% were lost to followup. Fifty-six percent of the deaths and 46% of those lost to followup occurred in the first year of treatment. Male gender (adjusted hazard ratio (AHR) was 3.26; 95% CI: 2.19–4.88); CD4 count ≤200 cells/μL (AHR 5.02; 95% CI: 2.03–12.39), tuberculosis (AHR 2.91; 95% CI: 2.11–4.02); bed-ridden functional status (AHR 12.88; 95% CI: 8.19–20.26) were predictors of mortality, whereas only CD4 count <200 cells/μL (HR = 1.33; 95% CI: (0.95, 1.88) and ambulatory functional status (HR = 1.65; 95% CI: (1.22, 2.23) were significantly associated with LTF. Conclusion. Loss to followup and mortality in the first year following enrollment remain a challenge for retention of patients in care. Strengthening patient monitoring can improve patient retention AIDS care.

Self-reported dietary intake and appetite predict early treatment outcome among low-BMI adults initiating HIV treatment in sub-Saharan Africa

OBJECTIVE

Low BMI is a major risk factor for early mortality among HIV-infected persons starting antiretrovial therapy (ART) in sub-Saharan Africa and the common patient belief that antiretroviral medications produce distressing levels of hunger is a barrier to treatment adherence. We assessed relationships between appetite, dietary intake and treatment outcome 12 weeks after ART initiation among HIV-infected adults with advanced malnutrition and immunosuppression.

DESIGN

A prospective, observational cohort study. Dietary intake was assessed using a 24 h recall survey. The relationships of appetite, intake and treatment outcome were analysed using time-varying Cox models.

SETTING

A public-sector HIV clinic in Lusaka, Zambia.

SUBJECTS

One hundred and forty-two HIV-infected adults starting ART with BMI <16 kg/m2 and/or CD4+ lymphocyte count <50 cells/μl.

RESULTS

Median age, BMI and CD4+ lymphocyte count were 32 years, 16 kg/m2 and 34 cells/μl, respectively. Twenty-five participants (18%) died before 12 weeks and another thirty-three (23%) were lost to care. A 500 kJ/d higher energy intake at any time after ART initiation was associated with an approximate 16% reduction in the hazard of death (adjusted hazard ratio = 0.84; P = 0.01), but the relative contribution of carbohydrate, protein or fat to total energy was not a significant predictor of outcome. Appetite normalized gradually among survivors and hunger was rarely reported.

CONCLUSIONS

Poor early ART outcomes were strikingly high in a cohort of HIV-infected adults with advanced malnutrition and mortality was predicted by lower dietary intake. Intervention trials to promote post-ART intake in this population may benefit survival and are warranted.

Predictors of mortality among HIV infected patients taking antiretroviral treatment in Ethiopia: a retrospective cohort study

Background

Studies indicate that there is high early mortality among patients starting antiretroviral treatment in sub-Saharan Africa. However, there is paucity of evidence on long term survival of patients on anti-retroviral treatment in the region. The objective of this study is to examine mortality and its predictors among a cohort of HIV infected patients on anti-retroviral treatment retrospectively followed for five years.

Methods

A retrospective cohort study was conducted among HIV infected patients on ART in eastern Ethiopia. Cox regression and Kaplan-Meier analyses were performed to investigate factors that influence time to death and survival over time.

Result

A total of 1540 study participants were included in the study. From the registered patients in the cohort, the outcome of patients as active, deceased, lost to follow up and transfer out was 1005 (67.2%), 86 (5.9%), 210 (14.0%) and 192 (12.8%) respectively. The overall mortality rate provides an incidence density of 2.03 deaths per 100 person years (95% CI 1.64 - 2.50). Out of a total of 86 deaths over 60 month period; 63 (73.3%) died during the first 12 months, 10 (11.6%) during the second year, and 10 (11.6%) in the third year of follow up. In multivariate analysis, the independent predictors for mortality were loss of more 10% weight loss, bedridden functional status at baseline, ≤ 200 CD4 cell count/ml, and advanced WHO stage patients.

Conclusion

A lower level of mortality was detected among the cohort of patients on antiretroviral treatment in eastern Ethiopia. Previous history of weight loss, bedridden functional status at baseline, low CD4 cell count and advanced WHO status patients had a higher risk of death. Early initiation of ART, provision of nutritional support and strengthening of the food by prescription initiative, and counseling of patients for early presentation to treatment is recommended.

Early mortality in adults initiating antiretroviral therapy (ART) in low- and middle-income countries (LMIC): a systematic review and meta-analysis

Background

We systematically reviewed observational studies of early mortality post-antiretroviral therapy (ART) initiation in low- and middle-income countries (LMIC) in Asia, Africa, and Central and South America, as defined by the World Bank, to summarize what is known.

Methods and Findings

Studies published in English between January 1996 and December 2010 were searched in Medline and EMBASE. Three independent reviewers examined studies of mortality within one year post-ART. An article was included if the study was conducted in a LMIC, participants were initiating ART in a non-clinical trial setting and were ≥15 years. Fifty studies were included; 38 (76%) from sub-Saharan Africa (SSA), 5 (10%) from Asia, 2 (4%) from the Americas, and 5 (10%) were multi-regional. Median follow-up time and pre-ART CD4 cell count ranged from 3–55 months and 11–192 cells/mm³, respectively. Loss-to-follow-up, reported in 40 (80%) studies, ranged from 0.3%–27%. Overall, SSA had the highest pooled 12-month mortality probability of 0.17 (95% CI 0.11–0.24) versus 0.11 (95% CI 0.10–0.13) for Asia, and 0.07 (95% CI 0.007–0.20) for the Americas. Of 14 (28%) studies reporting cause-specific mortality, tuberculosis (TB) (5%–44%), wasting (5%–53%), advanced HIV (20%–37%), and chronic diarrhea (10%–25%) were most common. Independent factors associated with early mortality in 30 (60%) studies included: low baseline CD4 cell count, male sex, advanced World Health Organization clinical stage, low body mass index, anemia, age greater than 40 years, and pre-ART quantitative HIV RNA.

Conclusions

Significant heterogeneity in outcomes and in methods of reporting outcomes exist among published studies evaluating mortality in the first year after ART initiation in LMIC. Early mortality rates are highest in SSA, and opportunistic illnesses such as TB and wasting syndrome are the most common reported causes of death. Strategies addressing modifiable risk factors associated with early death are urgently needed.

Association of pre-treatment nutritional status with change in CD4 count after antiretroviral therapy at 6, 12, and 24 months in Rwandan women

BACKGROUND

Body mass index (BMI) independently predicts mortality in studies of HIV infected patients initiating antiretroviral therapy (ART). We hypothesized that poorer nutritional status would be associated with smaller gains in CD4 count in Rwandan women initiating ART.

METHODS AND FINDINGS

The Rwandan Women's Interassociation Study and Assessment, enrolled 710 ART-naïve HIV-positive and 226 HIV-negative women in 2005 with follow-up every 6 months. The outcome assessed in this study was change in CD4 count at 6, 12, and 24 months after ART initiation. Nutritional status measures taken prior to ART initiation were BMI; height adjusted fat free mass (FFMI); height adjusted fat mass (FMI), and sum of skinfold measurements. 475 women initiated ART. Mean (within 6 months) pre-ART CD4 count was 216 cells/µL. Prior to ART initiation, the mean (±SD) BMI was 21.6 (±3.78) kg/m(2) (18.3% malnourished with BMI<18.5); and among women for whom the following were measured, mean FFMI was 17.10 (±1.76) kg/m(2); FMI 4.7 (±3.5) kg/m(2) and sum of skinfold measurements 4.9 (±2.7) cm. FFMI was significantly associated with a smaller change in CD4 count at 6 months in univariate analysis (-6.7 cells/uL per kg/m(2), p=0.03) only. In multivariate analysis after adjustment for covariates, no nutritional variable was associated with change in CD4 count at any follow up visit.

CONCLUSION

In this cohort of African women initiating ART, no measure of malnutrition prior to ART was consistently associated with change in CD4 count at 6, 12, and 24 months of follow up, suggesting that poorer pre-treatment nutritional status does not prevent an excellent response to ART.

Development and validation of a clinical score for prognosis stratification in patients requiring antiretroviral therapy in sub-Saharan Africa: a prospective open cohort study

Background

Mortality rates among patients initiating antiretroviral therapy (ART) in sub-Saharan Africa continue high. Also HIV treatment services from the region are affronting the challenges of been attending more patients than never. In this scenario, there are no integrated scoring systems capable of an adequate risk identification/ prognostic stratification among patients requiring ART; in order of optimize actual programmes outcomes. Several independent risk factors at baseline are associated with a poor prognosis after ART initiation. These include: male sex, low body mass index, anemia, low CD4 count and stage-4 WHO disease. The aim of this research was evaluate prospectively a new scoring system composed by these factors.

Methods

An open cohort study was conducted in 1769 patients from May 2008 to December 2010 at two HIV clinics of Zimbabwe. A new clinical model (MASIB score) was applied at ART initiation and patients were followed for 4 months. After that, validation characteristics of the score were examined.

Results

Patients selected in this cohort exhibited similar baseline characteristics that the patients selected in previous cohorts from the region. Overall performance for mortality prediction of MASIB score was accurate, as reflected by the Brier score test result 0.084 (95%CI: 0.080–0.088). Calibration was adequate taking in consideration a p>0.05 in the Hosmer Lemeshow test and discrimination was also good (Area Under Curve: 0.915, 95%CI: 0,901– 0,928).

Conclusion

The new model developed exhibited adequate validation characteristics supporting the clinical use. Further evaluations of this model in others scenarios from the sub-Saharan region are needed.

Changing predictors of mortality over time from cART start: implications for care

OBJECTIVE

To determine predictors of mortality and changes in those predictors over time on combination antiretroviral therapy (cART) in South Africa.

DESIGN

A cohort study.

METHODS

Using routine clinic data with up to 4 years follow-up after antiretroviral therapy initiation and with death ascertainment from a national vital statistics register, we used proportional hazards modeling to assess baseline and time-updated predictors of mortality and changes in strength of those predictors over time on cART. Furthermore, we compared CD4 count among individuals who died by duration on cART.

RESULTS

Fifteen thousand sixty subjects (64% men, median CD4 count 127 cells/mm³) started antiretroviral therapy between January 2003 and January 2008. Over a median follow-up of 1.8 years, 2658 subjects died. The baseline characteristics of WHO stage, hemoglobin, CD4 count, HIV RNA level, and symptoms were all associated with mortality during the first 12 months of cART but lost association thereafter. However, time-updated factors of CD4 count, body mass index, symptoms, anemia, and HIV RNA suppression remained strong predictors of death. Most recent CD4 count before death rose from 71 during the first 3 months of cART to 175 cells per cubic millimeter after >3 years of cART.

CONCLUSION

Over 4 years of cART, risk of death declined and associations with mortality changed. An increase in CD4 count at death and changing associations with mortality may suggest a shift in causes of death, possibly from opportunistic infections to other infections and chronic illnesses.

Current status of medication adherence and infant follow up in the prevention of mother to child HIV transmission programme in Addis Ababa: a cohort study

Background

Prevention of mother to child HIV transmission (PMTCT) programmes have great potential to achieve virtual elimination of perinatal HIV transmission provided that PMTCT recommendations are properly followed. This study assessed mothers and infants adherence to medication regimen for PMTCT and the proportions of exposed infants who were followed up in the PMTCT programme.

Methods

A prospective cohort study was conducted among 282 HIV-positive mothers attending 15 health facilities in Addis Ababa, Ethiopia. Descriptive statistics, bivariate and mulitivariate logistic regression analyses were done.

Results

Of 282 mothers enrolled in the cohort, 232 (82%, 95% CI 77-86%) initiated medication during pregnancy, 154 (64%) initiated combined zidovudine (ZDV) prophylaxis regimen while 78 (33%) were initiated lifelong antiretroviral treatment (ART). In total, 171 (60%, 95% CI 55-66%) mothers ingested medication during labour. Of the 221 live born infants (including two sets of twins), 191 (87%, 95% CI 81-90%) ingested ZDV and single-dose nevirapine (sdNVP) at birth. Of the 219 live births (twin births were counted once), 148 (68%, 95% CI 61-73%) mother-infant pairs ingested their medication at birth. Medication ingested by mother-infant pairs at birth was significantly and independently associated with place of delivery. Mother-infant pairs attended in health facilities at birth were more likely (OR 6.7 95% CI 2.90-21.65) to ingest their medication than those who were attended at home. Overall, 189 (86%, 95% CI 80-90%) infants were brought for first pentavalent vaccine and 115 (52%, 95% CI 45-58%) for early infant diagnosis at six-weeks postpartum. Among the infants brought for early diagnosis, 71 (32%, 95% CI 26-39%) had documented HIV test results and six (8.4%) were HIV positive.

Conclusions

We found a progressive decline in medication adherence across the perinatal period. There is a big gap between mediation initiated during pregnancy and actually ingested by the mother-infant pairs at birth. Follow up for HIV-exposed infants seem not to be organized and is inconsistent. In order to maximize effectiveness of the PMTCT programme, the rate of institutional delivery should be increased, the quality of obstetric services should be improved and missed opportunities to exposed infant follow up should be minimized.

Four-year treatment outcomes of adult patients enrolled in Mozambique's rapidly expanding antiretroviral therapy program

Background

In Mozambique during 2004–2007 numbers of adult patients (≥15 years old) enrolled on antiretroviral therapy (ART) increased about 16-fold, from <5,000 to 79,500. All ART patients were eligible for co-trimoxazole. ART program outcomes, and determinants of outcomes, have not yet been reported.

Methodology/Principal Findings

In a retrospective cohort study, we investigated rates of mortality, attrition (death, loss to follow-up, or treatment cessation), immunologic treatment failure, and regimen-switch, as well as determinants of selected outcomes, among a nationally representative sample of 2,596 adults initiating ART during 2004–2007. At ART initiation, median age of patients was 34 and 62% were female. Malnutrition and advanced disease were common; 18% of patients weighed <45 kilograms, and 15% were WHO stage IV. Median baseline CD4⁺ T-cell count was 153/µL and was lower for males than females (139/µL vs. 159/µL, p<0.01). Stavudine, lamivudine, and nevirapine or efavirenz were prescribed to 88% of patients; only 31% were prescribed co-trimoxazole. Mortality and attrition rates were 3.4 deaths and 19.8 attritions per 100 patient-years overall, and 12.9 deaths and 57.2 attritions per 100 patient-years in the first 90 days. Predictors of attrition included male sex [adjusted hazard ratio (AHR) 1.5; 95% confidence interval (CI), 1.3–1.8], weight <45 kg (AHR 2.1; 95% CI, 1.6–2.9, reference group >60 kg), WHO stage IV (AHR 1.7; 95% CI, 1.3–2.4, reference group WHO stage I/II), lack of co-trimoxazole prescription (AHR 1.4; 95% CI, 1.0–1.8), and later calendar year of ART initiation (AHR 1.5; 95% CI, 1.2–1.8). Rates of immunologic treatment failure and regimen-switch were 14.0 and 0.6 events per 100-patient years, respectively.

Conclusions

ART initiation at earlier disease stages and scale-up of co-trimoxazole among ART patients could improve outcomes. Research to determine reasons for low regimen-switch rates and increasing rates of attrition during program expansion is needed.

Correcting for mortality among patients lost to follow up on antiretroviral therapy in South Africa: a cohort analysis

Background

Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system.

Methods and Findings

We included 6411 patients enrolled on ART between March 2001 and June 2007. Patients LTF with available civil identification numbers were matched with the national vital registration system to ascertain vital status. Corrected mortality and true LTF were determined by weighting these patients to represent all patients LTF. We used Kaplan-Meier estimates and Cox regression to describe LTF, mortality among those LTF, and true LTF. Of 627 patients LTF, 85 (28.8%) had died within 3 months after their last clinic visits. Respective estimates of LTF before and after correction for mortality were 6.9% (95% confidence interval [CI] 6.2–7.6) and 4.3% (95% CI 3.5–5.3) at one year on ART, and 23.9% (95% CI 21.0–27.2) and 19.7% (95% CI 16.1–23.7) at 5 years. After correction for mortality, the hazard of LTF was reversed from decreasing to increasing with time on ART. Younger age, higher baseline CD4 count, pregnancy and increasing calendar year were associated with higher true LTF. Mortality of patients LTF at 1, 12 and 24 months after their last visits was respectively 23.1%, 30.9% and 43.8%; 78.0% of deaths occurred during the first 3 months after last visit and 45.0% in patients on ART for 0 to 3 months.

Conclusions

Mortality of patients LTF was high and occurred early after last clinic visit, especially in patients recently started on ART. Correction for these misclassified deaths revealed that the risk of true LTF increased over time. Research targeting groups at higher risk of LTF (youth, pregnant women and patients with higher CD4 counts) is needed.

Role of Nutrition in HIV Infection: Review of Evidence for more Effective Programming in Resource-Limited Settings

Background

HIV infection and malnutrition negatively reinforce each other.

Objective

For program guidance, to review evidence on the relationship of HIV infection and malnutrition in adults in resource-limited settings.

Results and conclusions

Adequate nutritional status supports immunity and physical performance. Weight loss, caused by low dietary intake (loss of appetite, mouth ulcers, food insecurity), malabsorption, and altered metabolism, is common in HIV infection. Regaining weight, particularly muscle mass, requires antiretroviral therapy (ART), treatment of opportunistic infections, consumption of a balanced diet, physical activity, mitigation of side effects, and perhaps appetite stimulants and growth hormone. Correcting nutritional status becomes more difficult as infection progresses. Studies document widespread micronutrient deficiencies among HIV-infected people. However, supplement composition, patient characteristics, and treatments vary widely across intervention studies. Therefore, the World Health Organization (WHO) recommends ensuring intake of 1 Recommended Nutrient Intake (RNI) of each required micronutrient, which may require taking micronutrient supplements. Few studies have assessed the impact of food supplements. Because the mortality risk in patients receiving ART increases with lower body mass index (BMI), improving the BMI seems important. Whether this requires provision of food supplements depends on the patient's diet and food security. It appears that starting ART improves BMI and that ready-to-use fortified spreads and fortified-blended foods further increase BMI (the effect is somewhat less with fortified-blended foods). The studies are too small to assess effects on mortality. Once ART has been established and malnutrition treated, the nutritional quality of the diet remains important, also because of ART's long-term metabolic effects (dyslipidemia, insulin resistance, obesity). Food insecurity should also be addressed if it prevents adequate energy intake and reduces treatment initiation and adherence (due to the opportunity costs of obtaining treatment and mitigating side effects).

Food Insecurity in the Context of HIV/AIDS: A Framework for a New Era of Programming

Background

Food insecurity can be both a consequence and a driver of HIV/AIDS. It is often difficult to disentangle these two roles of food insecurity, since the HIV epidemic has different drivers in different settings. The advent of antiretroviral treatment in resource-limited settings adds an additional layer of complexity. This paper seeks to organize current thinking by reviewing the existing literature on food insecurity and HIV/AIDS and describing the complex interactions between them.

Objective

Based on literature review, the paper proposes a framework to understand the linkages, distinguishing four types of interventions to address them. It is hoped that the model, albeit simplified as is any framework, will help to structure research, policy, and programming in the field of HIV/AIDS and food insecurity. Finally, the paper intends to widen the lens to regard food not just as a means to provide calories or an income transfer but also as a carrier of adequate nutrition in the context of HIV.

Results and conclusions

An adequate response to HIV/AIDS and food insecurity must be tailored to specific settings. Interventions distinguished in this paper are aimed at both promoting food security and providing antiretroviral treatment and nutrition support. The four types of interventions are containing HIV and preventing AIDS through comprehensive treatment regimes that include nutritional support; mitigating the effects of AIDS through support; providing HIV-sensitive, but not HIV-exclusive, safety nets at the individual, household, and community levels; and limiting the exposure to risk through HIV prevention activities.

Antiretroviral treatment-associated tuberculosis in a prospective cohort of HIV-infected patients starting ART

Commencement of antiretroviral treatment (ART) in severely immunosuppressed HIV-infected persons is associated with unmasking of subclinical disease. The subset of patients that are diagnosed with tuberculosis (TB) disease while on ART have been classified as ART-associated TB. Few studies have reported the incidence of ART-associated TB and unmasking TB-IRIS according to the International Network for the Study of HIV-Associated IRIS (INSHI) consensus definition. To determine the incidence and predictors of ART-associated TB, we screened 219 patients commencing ART at the Infectious Diseases Clinic in Kampala, Uganda for TB by symptoms, sputum microscopy, and chest X-rays and followed them for one year. Fourteen (6.4%) patients were diagnosed with TB during followup. Eight (3.8%) patients had ART-associated TB (incidence rate of 4.3 per 100 person years); of these, three patients fulfilled INSHI criteria for unmasking TB-associated IRIS (incidence rate of 1.6 per 100 person years). A body mass index of less than 18.5 kg/m² BMI (HR 5.85 95% CI 1.24–27.46, P = .025) and a C-reactive protein greater than 5 mg/L (HR 8.23 95% CI 1.36–38.33, P = .020) were risk factors for ART-associated TB at multivariate analysis. In conclusion, with systematic TB screening (including culture and chest X-ray), the incidence of ART-associated TB is relatively low in settings with high HIV and TB prevalence.

Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia

BACKGROUND

The antiretroviral treatment (ART) scale-up service has been a recent development in Ethiopia, but its impact on mortality has not been well investigated. The aim of this study was to assess the early survival outcome of the scale-up service by utilizing routine hospital data.

METHODS

All adult HIV/AIDS patients who started on antiretroviral treatment in Shashemene and Assela hospitals from January 1, 2006 to May 31, 2006 were included and followed up for 2 years. Data were extracted from standard patient medical registrations. Kaplan-Meier curves were used to estimate survival probability and the Cox proportional hazard model was applied to determine predictors of mortality. Two alterative assumptions (real case and worst case) were made in determining predictors of mortality.

RESULTS

The median age of patients was 33 years and 57% were female. Eighty-five percent had CD4 <200 cells/µL with a median CD4 count of 103 cells/µL. The median survival time was 104.4 weeks. A total of 28 (10.3%) deaths were observed during the 2-year period and 48 patients (18%) were lost to follow up. The majority of deaths occurred in the first 4 months of treatment. In multivariate analysis, 2-year survival was significantly associated with the clinical stage of the disease, baseline hemoglobin, and cotrimoxazole prophylaxis therapy (CPT) at or before ART initiation in both assumptions. The median CD4 count and body weight showed a marked improvement during the first 6 months of treatment, followed by stagnation thereafter.

CONCLUSION

The study has shown an overall low mortality but a high loss to follow-up rate of the cohort. Advanced clinical stage, anemia, low body weight, and lack of CPT initiation were independent predictors of mortality - but not gender. CPT initiation should be encouraged in routine HIV care services, and patient retention mechanisms have to be strengthened. Stagnation in immunological and weight recovery after the first 6 months should be further investigated. The utilization of routine data should be encouraged in order to facilitate appropriate decision making.

Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia

BACKGROUND

Previous studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. One of the reasons was late presentation of patients to care. With improved access to HIV services, we expect improvements in disease stage at presentation. Our objective was to assess the effect of improved availability of HIV services on patient presentation to care and subsequent pre-ART and on-ART outcomes.

METHODOLOGY AND PRINCIPAL FINDINGS

At Arba Minch Hospital in Ethiopia, we reviewed baseline characteristics and outcomes of 2191 adult HIV patients. Nearly a half were in WHO stage III at presentation. About two-thirds of the patients (1428) started ART. Patients enrolled in the early phase (OR = 4.03, 95% CI 3.07-5.27), men (OR = 1.78, 95%CI 1.47-2.16), and those aged 45 years and above (OR = 2.04, 95%CI 1.48-2.82) were at higher risk of being in advanced clinical stage at presentation. The pre-treatment mortality rate was 13.1 per 100 PYO, ranging from 1.4 in the rapid scale-up phase to 25.9 per 100 PYO in the early phase. A quarter of the patients were lost to follow-up before starting treatment. Being in less advanced stage (HR = 1.9, 95% CI = 1.6, 2.2), being in the recent cohort (HR = 2.0, 95% CI = 1.6, 2.6), and rural residence (HR = 1.8, 95% CI = 1.5, 2.2) were independent predictors of pre-ART loss to follow-up. Of those who started ART, 13.4% were lost to follow-up and 15.4% died. The survival improved during the study. Patients with advanced disease, men and older people had higher death rates.

CONCLUSIONS AND SIGNIFICANCE

Patients started to present at earlier stages of their illness and death has decreased among adult HIV patients visiting Arba Minch Hospital. However, many patients were lost from pre-treatment follow-up. Early treatment start contributed to improved survival. Both pre-ART and on-ART patient retention mechanisms should be strengthened.

Lactation-associated postpartum weight changes among HIV-infected women in Zambia

BACKGROUND

There are concerns about effects of lactation on postpartum weight changes among HIV-infected women because low weight may increase risks of HIV-related disease progression.

METHODS

This analysis of postpartum maternal weight change is based on a trial evaluating the effects of shortened breastfeeding on postpartum mother-to-child transmission of HIV in Lusaka, Zambia, in which 958 HIV-infected women were randomized to breastfeed for a short duration (4 months) or for a duration of their own informed choosing (median 16 months). Among 768 women who met inclusion criteria, we compared across the two groups change in weight (kg) and the percent underweight [body mass index (BMI) <18.5] through 24 months. We also examined the effect of breastfeeding in two high-risk groups: those with low BMI and those with low CD4 counts.

RESULTS

Overall, women in the long-duration group gained less weight compared with those in the short-duration group from 4-24 months {1.0 kg [95% confidence interval (CI): 0.3-1.7] vs 2.3 kg (95% CI: 1.6-2.9), P = 0.01}. No association was found between longer breastfeeding and being underweight (odds ratio 1.1; 95% CI: 0.8-1.6; P = 0.40). Effects of lactation in underweight women and women with low CD4 counts were similar to the effects in women with higher BMI and higher CD4 counts. Women with low baseline BMI tended to gain more weight from 4 to 24 months than those with higher BMI, regardless of breastfeeding duration (2.1 kg, 95% CI: 1.3-2.9; P < 0.01).

CONCLUSIONS

In this study of HIV-infected breastfeeding women in a low-resource setting, the average change in weight from 4 to 24 months postpartum was a net gain rather than loss. Although longer duration breastfeeding was associated with less weight gain, breastfeeding duration was not associated with being underweight (BMI < 18.5). Weight change associated with longer breastfeeding may be metabolically regulated so that women with low BMI and at risk of wasting are protected from excess weight loss.

Serum phosphate predicts early mortality in adults starting antiretroviral therapy in Lusaka, Zambia: a prospective cohort study

Background

Patients starting antiretroviral therapy (ART) for acquired immunodeficiency syndrome (AIDS) in sub-Saharan Africa have high rates of mortality in the initial weeks of treatment. We assessed the association of serum phosphate with early mortality among HIV-infected adults with severe malnutrition and/or advanced immunosuppression.

Methodology/Principal Findings

An observational cohort of 142 HIV-infected adults initiating ART in Lusaka, Zambia with body mass index (BMI) <16 kg/m² or CD4⁺ lymphocyte count <50 cells/µL, or both, was followed prospectively during the first 12 weeks of ART. Detailed health and dietary intake history, review of systems, physical examination, serum metabolic panel including phosphate, and serum ferritin and high-sensitivity C-reactive protein (hsCRP) were monitored. The primary outcome was mortality. Baseline serum phosphate was a significant predictor of mortality; participants alive at 12 weeks had a median value of 1.30 mmol/L (interquartile range [IQR]: 1.04, 1.43), compared to 1.06 mmol/L (IQR: 0.89, 1.27) among those who died (p<0.01). Each 0.1 mmol/L increase in baseline phosphate was associated with an incremental decrease in mortality (AHR 0.83; 95% CI 0.72 to 0.95). The association was independent of other metabolic parameters and known risk factors for early ART-associated mortality in sub-Saharan Africa. While participant attrition represented a limitation, it was consistent with local program experience.

Conclusions/Significance

Low serum phosphate at ART initiation was an independent predictor of early mortality among HIV patients starting ART with severe malnutrition or advanced immunosuppression. This may represent a physiologic phenomenon similar to refeeding syndrome, and may lead to therapeutic interventions that could reduce mortality.

The health related quality of life of people living with HIV/AIDS in sub-Saharan Africa - a literature review and focus group study

Background

While health outcomes of HIV/AIDS treatments in terms of increased longevity has been the subject of much research, there appears to be very limited research on the improved health related quality of life (HRQL) that can be applied in cost-utility analyses in Africa south of the Sahara (SSA). Most of the literature that does exist present HRQL measured by disease specific instruments, but such data is of little use as input to economic evaluations.

Methods

A systematic review of the literature on HRQL weights for people living with HIV/AIDS in Africa was performed, and the findings are presented and interpreted. We also use focus group discussions in panels of clinical AIDS experts to test the preference based on a generic descriptive system EQ-5D. We contrast quality of life with and without antiretroviral treatment (ART), and with and without treatment failure.

Results

In only four papers were the HRQL weights for HIV/AIDS in sub-Saharan Africa estimated with generic preference based methodologies that can be directly applied in economic evaluation. A total of eight studies were based on generic health profiles. While such 'health profiles' are not preference based, the scores could potentially be transformed into health state utilities. Most of the available literature (20 papers) utilized disease specific instrument, which are not applicable for economic evaluation.

The focus group discussions revealed that HRQL weights are strongly correlated to disease stage. Furthermore, clinical experts consistently report that ART has a strong positive impact on the HRQL of patients, although this effect appears to rebound in cases of drug resistance.

Conclusions

EQ-5D appears to be an appropriate tool for measuring and valuing HRQL of HIV/AIDS in Africa. More empirical research is needed on various methodological aspects in order to obtain valid and reliable HRQL weights in economic evaluations of HIV/AIDS prevention and treatment interventions.

Macronutrient supplementation and food prices in HIV treatment

Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.

High early mortality in patients with chronic acquired immunodeficiency syndrome diarrhea initiating antiretroviral therapy in Haiti: a case-control study

This case-control study examines whether chronic diarrhea at initiation of antiretroviral therapy (ART) affects survival of human immunodefiency virus-infected patients. Cases (288) were treatment-naive, non-pregnant, adults with self report of frequent loose stool for > 3 weeks at the time ART was initiated. One-third of patients had an enteric pathogen identified including Cryptosporidium spp., Giardia spp., Isospora belli, Cyclospora cayetanensis, and Entamoeba histolytica. Control patients (400) did not have diarrhea when initiating ART. At six weeks, mortality was 10% in the patients with diarrhea and 5% in the patients without diarrhea (P = 0.009). Chronic diarrhea in patients requesting ART in Haiti is associated with increased early mortality.

Weight gain at 3 months of antiretroviral therapy is strongly associated with survival: evidence from two developing countries

BACKGROUND

In developing countries, access to laboratory tests remains limited, and the use of simple tools such as weight to monitor HIV-infected patients treated with antiretroviral therapy should be evaluated.

METHODS

Cohort study of 2451 Cambodian and 2618 Kenyan adults who initiated antiretroviral therapy between 2001 and 2007. The prognostic value of weight gain at 3 months of antiretroviral therapy on 3-6 months mortality, and at 6 months on 6-12 months mortality, was investigated using Poisson regression.

RESULTS

Mortality rates [95% confidence interval (CI)] between 3 and 6 months of antiretroviral therapy were 9.9 (7.6-12.7) and 13.5 (11.0-16.7) per 100 person-years in Cambodia and Kenya, respectively. At 3 months, among patients with initial body mass index less than or equal to 18.5 kg/m (43% of the study population), mortality rate ratios (95% CI) were 6.3 (3.0-13.1) and 3.4 (1.4-8.3) for those with weight gain less than or equal to 5 and 5-10%, respectively, compared with those with weight gain of more than 10%. At 6 months, weight gain was also predictive of subsequent mortality: mortality rate ratio (95% CI) was 7.3 (4.0-13.3) for those with weight gain less than or equal to 5% compared with those with weight gain of more than 10%.

CONCLUSION

Weight gain at 3 months is strongly associated with survival. Poor compliance or undiagnosed opportunistic infections should be investigated in patients with initial body mass index less than or equal to 18.5 and achieving weight gain less than or equal to 10%.

Patients with advanced HIV type 1 infection initiating antiretroviral therapy in Botswana: treatment response and mortality

The response to highly active antiretroviral treatment (HAART) and predictors of mortality among patients with advanced HIV infection (CD4(+) cell count <50 cells/mm(3)) in Botswana are described. Clinical and laboratory data for 349 patients with CD4 <50 cells/mm(3) initiating HAART from January 23 to November 18, 2002 at Princess Marina Hospital in Gaborone, Botswana were extracted from clinical charts and electronic patient management systems. The Kaplan-Meier method was used to estimate survival and log-rank tests used for group comparisons. Cox regression was used to identify independent predictors of survival. A total of 349 adults initiated HAART. In all, 78.2% (95% CI: 73.7%, 82.9%) of patients survived 1 year. Among survivors, the mean CD4(+) cell count increase was 239.8 cells/mm(3) (95% CI: 217.0, 262.8) at 12 months; 92.1% (95% CI: 87.8%, 94.9%) of patients (as treated) had plasma HIV-1 RNA < or =400 copies/ml at 9 months declining to 59.9% (95% CI: 54.7%, 64.9%) (ITT). There was a 2-fold higher mortality rate among patients with CD4(+) < or =10 cells/mm(3) compared to 11-49 cells/mm(3), hazard ratio (HR) = 1.91 (95% CI:1.16, 3.14). A 10 cell/mm(3) higher CD4(+) cell count corresponded to a 22% decrease in hazard of death (HR = 0.78; 95% CI: 0.64, 0.94). Lower baseline CD4(+) cell count (p < 0.001) and WHO clinical stage 4 HR = 2.41 (95% CI:1.32, 4.38) were independent predictors of poorer survival. HAART confers significant benefit even among persons with advanced immunosuppression. Adults with CD4(+) cell counts < or =10 cells/mm(3) and/or WHO clinical stage 4 disease at the time of HAART initiation have a higher risk of death.

Vertically acquired HIV diagnosed in adolescence and early adulthood in the United Kingdom and Ireland: findings from national surveillance

OBJECTIVE

The aim of the study was to describe the characteristics of young people with vertically acquired HIV diagnosed aged > or =13 years.

METHODS

A retrospective review of HIV diagnoses reported to well-established national paediatric and adult HIV surveillance systems in the United Kingdom/Ireland was conducted.

RESULTS

Forty-two young people with vertically acquired HIV diagnosed aged > or =13 years were identified; 23 (55%) were female, 40 (95%) were black African and 36 (86%) were born in sub-Saharan Africa. The median age at HIV diagnosis was 14 years (range, 13-20 years). Half of the patients presented with symptoms; the remainder were screened for HIV following diagnosis of a relative. The median CD4 count at diagnosis was 210 cells/microL (range, 0-689 cells/microL), 12 patients (29%) were diagnosed with AIDS at HIV diagnosis or subsequently, and 34 (81%) started combination antiretroviral therapy (ART), most (31 of 34) within a year of diagnosis.

CONCLUSION

A small number of young people with vertically acquired HIV survive childhood without ART and are diagnosed at age > or =13 years in the United Kingdom/Ireland. Half of the patients were asymptomatic, highlighting the importance of considering HIV testing for all offspring of HIV-infected women, regardless of age or symptoms. Increased awareness among clinicians and parents is required to reduce delayed presentation with advanced disease and to avoid onward transmission as these young people become sexually active.