Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study

Healthcare provider perceptions on the implementation of the universal test-and-treat policy in South Africa: a qualitative inquiry

BACKGROUND

South Africa had an estimated 7.5 million people living with HIV (PLHIV), accounting for approximately 20% of the 38.4 million PLHIV globally in 2021. In 2015, the World Health Organization recommended the universal test and treat (UTT) intervention which was implemented in South Africa in September 2016. Evidence shows that UTT implementation faces challenges in terms of human resources capacity or infrastructure. We aim to explore healthcare providers (HCPs)' perspectives on the implementation of the UTT strategy in uThukela District Municipality in KwaZulu-Natal province.

METHODS

A qualitative study was conducted with one hundred and sixty-one (161) healthcare providers (HCPs) within 18 healthcare facilities in three subdistricts, comprising of Managers, Nurses, and Lay workers. HCPs were interviewed using an open ended-survey questions to explore their perceptions providing HIV care under the UTT strategy. All interviews were thematically analysed using both inductive and deductive approaches.

RESULTS

Of the 161 participants (142 female and 19 male), 158 (98%) worked at the facility level, of which 82 (51%) were nurses, and 20 (12.5%) were managers (facility managers and PHC manager/supervisors). Despite a general acceptance of the UTT policy implementation, HCPs expressed challenges such as increased patient defaulter rates, increased work overload, caused by the increased number of service users, and physiological and psychological impacts. The surge in the workload under conditions of inadequate systems' capacity and human resources, gave rise to a greater burden on HCPs in this study. However, increased life expectancy, good quality of life, and immediate treatment initiation were identified as perceived positive outcomes of UTT on service users. Perceived influence of UTT on the health system included, increased number of patients initiated, decreased burden on the system, meeting the 90-90-90 targets, and financial aspects.

CONCLUSION

Health system strengthening such as providing more systems' capacity for expected increase in workload, proper training and retraining of HCPs with new policies in the management of patient readiness for lifelong ART journey, and ensuring availability of medicines, may reduce strain on HCPs, thus improving the delivery of the comprehensive UTT services to PLHIV.

Tuberculosis and HIV/AIDS-attributed mortalities and associated sociodemographic factors in Papua New Guinea: evidence from the comprehensive health and epidemiological surveillance system

OBJECTIVE

Tuberculosis (TB) and HIV/AIDS are public health concerns in Papua New Guinea (PNG). This study examines TB and HIV/AIDS mortalities and associated sociodemographic factors in PNG.

METHOD

As part of a longitudinal study, verbal autopsy (VA) interviews were conducted using the WHO 2016 VA Instrument to collect data of 926 deaths occurred in the communities within the catchment areas of the Comprehensive Health and Epidemiological Surveillance System from 2018 to 2020.InterVA-5 cause of deaths analytical tool was used to assign specific causes of death (COD). Multinomial logistic regression analyses were conducted to identify associated sociodemographic factors, estimate adjusted ORs (AOR), 95% CIs and p values.

RESULT

TB and HIV/AIDS were the leading CODs from infectious diseases, attributed to 9% and 8% of the total deaths, respectively.Young adults (25-34 years) had the highest proportion of deaths from TB (20%) and the risk of dying from TB among this age group was five times more likely than those aged 75+ years (AOR: 5.5 (95% CI 1.4 to 21.7)). Urban populations were 46% less likely to die from this disease compared rural ones although the difference was not significant (AOR: 0.54 (95% CI 0.3 to 1.0)). People from middle household wealth quintile were three times more likely to die from TB than those in the richest quintile (AOR: 3.0 (95% CI 1.3 to 7.4)).Young adults also had the highest proportion of deaths to HIV/AIDS (18%) and were nearly seven times more likely to die from this disease compared with those aged 75+years (AOR: 6.7 (95% CI 1.7 to 25.4)). Males were 48% less likely to die from HIV/AIDS than females (AOR: 0.52 (95% CI 0.3 to 0.9)). The risk of dying from HIV/AIDS in urban population was 54% less likely than their rural counterparts (AOR: 0.46 (95% CI 0.2 to 0.9)).

CONCLUSION

TB and HIV/AIDS interventions are needed to target vulnerable populations to reduce premature mortality from these diseases in PNG.

Predictors of Survival Time Among HIV-Infected Adults After Initiating Anti-Retroviral Therapy in Kombolcha Town: A 5-Year Retrospective Cohort Study

Background

Antiretroviral therapy (ART) enhances the survival of HIV-infected patients by reducing viral load and increasing CD4. As CD4 count increases, patients are more protected against opportunistic infections. In developing countries including Ethiopia, there were limited studies about the survival benefit of ART particularly no study in Kombolcha Town. Thus, this study was aimed to address the gap.

Methods

A hospital-based retrospective cohort study was employed in Kombolcha town among 510 patients’ records from January 2015 to December 2019. A systematic random sampling technique was used to select patient records. The collected data were checked, coded, and entered into Epidata version 4.6 and exported to Statistical Package for Social Sciences version 26 for data cleaning and analysis. Kaplan–Meier was used to estimate the probability of category of each predictor and a log rank test was used to compare survival curves. Bivariate and multivariate Cox-regression were employed using a 95% CI and variables with p-value <0.05 were declared as predictors of poor survival time.

Results

In this cohort, out of 510 HIV-infected patients, 39 (7.65%) were died, and 471 (92.35%) were censored. Fair drug adherence (AHR=6.88, 95% CI: 4.31–24.04), Poor drug adherence (AHR=9.58, 95% CI: 8.72–30.97), CD4 count <50 cell/µL (AHR=9.38, 95% CI: 1.48–59.31), CD4 count 50–99 cell/µL (AHR=9.67, 95% CI: 1.80–51.73), bedridden (AHR=9.5, 95% CI: 4.49–18.66), opportunistic infections (AHR=4.58, 95% CI: 1.20–5.65), weight <60kg (AHR=2.48, 95% CI:1.59, 10.38), WHO stage III (AHR=3.56, 95% CI: 1.71–17.89), WHO stage IV (AHR=4.42, 95% CI:1.75–25.93) were predictors of poor survival time.

Conclusion

The Kaplan–Meier result showed that the estimated median survival time of patients after ART initiation in Kombolcha town was higher (32 months) as compared to other studies. Poor drug adherence, WHO stage III & IV, Lower baseline CD4 count, presence of opportunistic infections, weight <60kg, and being bedridden were predictors of poor survival time. Thus, early initiation of ART ought to be encouraged among HIV-infected patients and good patient counseling on the level of adherence should be strengthened.

Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa

Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.

Improving retention of community-recruited participants in HIV prevention research through Saturday household visits; findings from the HPTN 071 (PopART) study in South Africa

BACKGROUND

Identifying successful strategies to improve participant retention in longitudinal studies remains a challenge. In this study we evaluated whether non-traditional fieldworker shifts (after hours during the week and weekends) enhanced participant retention when compared to retention during traditional weekday shifts in the HPTN 071 (PopART) population cohort (PC).

METHODS

HPTN 071 (PopART) PC participants were recruited and followed up in their homes on an annual basis by research fieldworkers over a 3-4 year period. The average number of successful follow-up visits, where a PC participant was found and retained in the study, was calculated for each of 3 visit schedules (early weekday shift, late weekday shift, and Saturday shift), and standardized to account for variation in fieldwork shift duration. We used one-way univariate analysis of variance (ANOVA) to describe differences in mean-successful visits and 95% confidence intervals between the shift types.

RESULTS

Data on 16 651 successful visits were included. Successful visit rates were higher when conducting Saturday visits (14.0; 95% CI: 11.3-16.6) compared to both regular (4.5; 95% CI: 3.7-5.3) and late weekday shifts (5.3; 95% CI: 4.7-5.8) overall and in all subgroup analyses (P<0.001). The successful visit rate was higher amongst women than men were during all shift types (3.2 vs. 1.3, p<0.001). Successful visit rates by shift type did not differ significantly by age, over time, by PC round or by community triplet.

CONCLUSION

The number of people living with HIV continues to increase annually. High quality evidence from longitudinal studies remains critical for evaluating HIV prevention and treatment strategies. This study showed a significant benefit on participant retention through introduction of Saturday shifts for home visits and these data can make an important contribution to the emerging body of evidence for improving retention in longitudinal research.

TRIAL REGISTRATION

PopART was approved by the Stellenbosch University Health Research Ethics Committees (N12/11/074), London School of Hygiene and Tropical Medicine (6326) ethics committee and the Division of AIDS (DAIDS) (Protocol ID 11865). PopART was registered with ClinicalTrials.gov (registration number NCT01900977 ).

Prevalence of Untreated HIV and Associated Risk Behaviors Among the Sexual Partners of Recent Migrants and Long-term Residents in Rakai, Uganda

BACKGROUND

Migrants in sub-Saharan Africa are at increased risk of HIV acquisition after migration, but little is known about their sexual partners at place of destination.

SETTING

Rakai Community Cohort Study (RCCS) in Uganda.

METHODS

From 1999 to 2016, persons aged 15-49 years were surveyed in the RCCS and reported on their 4 most recent sexual partners in the last year. We compared the characteristics of sexual partners reported by migrants moving into RCCS communities in the last 2 years (ie, in-migrants) with those of long-term residents with no recent migration history. Among a subset of participants in cohabitating epidemiologically linked couples of known HIV serostatus, we also assessed prevalence of having ≥1 untreated HIV-positive partner among in-migrants and long-term residents.

RESULTS

One hundred sixteen thousand seven hundred forty-four sexual partners were reported by 29,423 participants. The sexual partnerships of in-migrants were significantly less likely to be marital, more likely to span community boundaries, and shorter in duration than those of long-term residents. In-migrants also reported more sexual partners and were less likely to know their partner's HIV status or to have told their partner their HIV status. Among 7558 epidemiologically linked couples, HIV-negative in-migrants were more likely to partner with untreated HIV-positive persons compared with HIV-negative long-term residents (women: 6.3% vs. 4.1%; prevalence risk ratio = 1.77, 95% confidence interval: 1.49 to 2.11; men: 6.9% vs. 3.9%; prevalence risk ratio = 1.72, 95% confidence interval: 1.38-2.14).

CONCLUSION

There is a higher frequency of risky sexual behaviors among the partnerships of in-migrants compared with those of long-term residents. Among cohabitating couples, in-migrants are more likely to partner with untreated HIV-positive individuals.

The impact of HIV status on the distance traveled to health facilities and adherence to care. A record-linkage study from rural South Africa

Background

For people living with HIV (PLWH), the burden of travelling to a clinic outside of one’s home community in order to reduce the level of stigma experienced, may impact adherence to treatment and accelerate disease progression.

Methods

This study is set in the Agincourt Health and Demographic Surveillance System (HDSS) in South Africa. Probabilistic and interactive methods were used to individually link HDSS data with medical records. A regression analysis was used to assess whether travel distance was correlated with the condition for which individuals were seeking care (primarily HIV, diabetes or hypertension). For PLWH, a Cox proportional hazard regression model was used to test for an association between the distance travelled to the clinic and late attendance at follow-up visits.

Results

The adjusted relative risk (RR) of travelling to a clinic more than 5 km from that nearest to their home for HIV patients compared to those being treated for other conditions was 2.78 (95% confidence interval (CI) = 2.23-3.48). The adjusted Cox regression model showed no evidence for an association between the distance travelled to a clinic and the rate of late visits. (RR = 1.00, 95% CI = 0.99-1.00).

Conclusions

The findings were consistent with the hypothesis that people living with HIV/AIDS would be willing to accept the burden of increased clinic travel distances in order to maintain anonymity and so limit their exposure to stigma from fellow community members. For those seeking HIV care the lack of an association between increased travel distances and late visit attendance suggests this may not impact treatment outcomes.

Brief Report: HIV Incidence Among Older Adults in a Rural South African Setting: 2010-2015

In South Africa, evidence shows high HIV prevalence in older populations, with sexual behavior consistent with high HIV acquisition and transmission risk. However, there is a dearth of evidence on older people's HIV incidence.

The winding road to health: A systematic scoping review on the effect of geographical accessibility to health care on infectious diseases in low- and middle-income countries

BACKGROUND

Geographical accessibility to healthcare is an important component of infectious disease dynamics. Timely access to health facilities can prevent disease progression and enables disease notification through surveillance systems. The importance of accounting for physical accessibility in response to infectious diseases is increasingly recognized. Yet, there is no comprehensive review of the literature available on infectious diseases in relation to geographical accessibility to care. Therefore, we aimed at evaluating the current state of knowledge on the effect of geographical accessibility to health care on infectious diseases in low- and middle-income countries.

METHODS AND FINDINGS

A search strategy was developed and conducted on Web of Science and PubMed on 4 March 2019. New publications were checked until May 28, 2020. All publication dates were eligible. Data was charted into a tabular format and descriptive data analyses were carried out to identify geographical regions, infectious diseases, and measures of physical accessibility among other factors. Search queries in PubMed and Web of Science yielded 560 unique publications. After title and abstract screening 99 articles were read in full detail, from which 64 articles were selected, including 10 manually. Results of the included publications could be broadly categorized into three groups: (1) decreased spatial accessibility to health care was associated with a higher infectious disease burden, (2) decreased accessibility was associated to lower disease reporting, minimizing true understanding of disease distribution, and (3) the occurrence of an infectious disease outbreak negatively impacted health care accessibility in affected regions. In the majority of studies, poor geographical accessibility to health care was associated with higher disease incidence, more severe health outcomes, higher mortality, and lower disease reporting. No difference was seen between countries or infectious diseases.

CONCLUSIONS

Currently, policy-makers and scientists rely on data collected through passive surveillance systems, introducing uncertainty on disease estimates for remote communities. Our results highlight the need for increasing integration of geographical accessibility measures in disease risk modelling, allowing more realistic disease estimates and enhancing our understanding of true disease burden. Additionally, disease risk estimates could be used in turn to optimize the allocation of health services in the prevention and detection of infectious diseases.

Migration, hotspots, and dispersal of HIV infection in Rakai, Uganda

HIV prevalence varies markedly throughout Africa, and it is often presumed areas of higher HIV prevalence (i.e., hotspots) serve as sources of infection to neighboring areas of lower prevalence. However, the small-scale geography of migration networks and movement of HIV-positive individuals between communities is poorly understood. Here, we use population-based data from ~22,000 persons of known HIV status to characterize migratory patterns and their relationship to HIV among 38 communities in Rakai, Uganda with HIV prevalence ranging from 9 to 43%. We find that migrants moving into hotspots had significantly higher HIV prevalence than migrants moving elsewhere, but out-migration from hotspots was geographically dispersed, contributing minimally to HIV burden in destination locations. Our results challenge the assumption that high prevalence hotspots are drivers of transmission in regional epidemics, instead suggesting that migrants with high HIV prevalence, particularly women, selectively migrate to these areas.

Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study

Introduction

Despite increased treatment availability, HIV-infected individuals continue to start antiretroviral therapy (ART) late in disease progression, increasing early mortality risk.

Materials and methods

Nested prospective cohort study within a randomized clinical trial of adult patients initiating ART at clinics in urban Nairobi and rural Maseno, Kenya, between 2013–2014. We estimated mortality incidence rates following ART initiation and used Cox proportional hazards regression to identify predictors of mortality within 12 months of ART initiation. Analyses were stratified by clinic site to examine differences in mortality correlates and risk by location.

Results

Among 811 participants initiated on ART, the mortality incidence rate within a year of initiating ART was 7.44 per 100 person-years (95% CI 5.71, 9.69). Among 207 Maseno and 612 Nairobi participants initiated on ART, the mortality incidence rates (per 100 person-years) were 12.78 (95% CI 8.49, 19.23) and 5.72 (95% CI 4.05, 8.09). Maseno had a 2.20-fold greater risk of mortality than Nairobi (95% CI 1.29, 3.76; P = 0.004). This association remained [adjusted hazard ratio (HR) = 2.09 (95% CI 1.17, 3.74); P = 0.013] when adjusting for age, gender, education, pre-treatment drug resistance (PDR), and CD4 count, but not when adjusting for BMI. In unadjusted analyses, other predictors (P<0.05) of mortality included male gender (HR = 1.74), age (HR = 1.04 for 1-year increase), fewer years of education (HR = 0.92 for 1-year increase), unemployment (HR = 1.89), low body mass index (BMI<18.5 m/kg²; HR = 4.99), CD4 count <100 (HR = 11.67) and 100–199 (HR = 3.40) vs. 200–350 cells/μL, and pre-treatment drug resistance (PDR; HR = 2.49). The increased mortality risk associated with older age, males, and greater education remained when adjusted for location, age, education and PDR, but not when adjusted for BMI and CD4 count. PDR remained associated with increased mortality risk when adjusted for location, age, gender, education, and BMI, but not when adjusted for CD4 count. CD4 and BMI associations with increased mortality risk persisted in multivariable analyses. Despite similar baseline CD4 counts across locations, mortality risk associated with low CD4 count, low BMI, and PDR was greater in Maseno than Nairobi in stratified analyses.

Conclusions

High short-term post-ART mortality was observed, partially due to low CD4 count and BMI at presentation, especially in the rural setting. Male gender, older age, and markers of lower socioeconomic status were also associated with greater mortality risk. Engaging patients earlier in HIV infection remains critical. PDR may influence short-term mortality and further studies to optimize management will be important in settings with increasing PDR.

A comparison of all-cause and cause-specific mortality by household socioeconomic status across seven INDEPTH network health and demographic surveillance systems in sub-Saharan Africa

Background: Understanding socioeconomic disparities in all-cause and cause-specific mortality can help inform prevention and treatment strategies.

Objectives: To quantify cause-specific mortality rates by socioeconomic status across seven health and demographic surveillance systems (HDSS) in five countries (Ethiopia, Kenya, Malawi, Mozambique, and Nigeria) in the INDEPTH Network in sub-Saharan Africa.

Methods: We linked demographic residence data with household survey data containing living standards and education information we used to create a poverty index. Person-years lived and deaths between 2003 and 2016 (periods varied by HDSS) were stratified in each HDSS by age, sex, year, and number of deprivations on the poverty index (0–8). Causes of death were assigned to each death using the InterVA-4 model based on responses to verbal autopsy questionnaires. We estimated rate ratios between socioeconomic groups (2–4 and 5–8 deprivations on our poverty index compared to 0–2 deprivations) for specific causes of death and calculated life expectancy for the deprivation groups.

Results: Our pooled data contained almost 3.5 million person-years of observation and 25,038 deaths. All-cause mortality rates were higher among people in households with 5–8 deprivations on our poverty index compared to 0–2 deprivations, controlling for age, sex, and year (rate ratios ranged 1.42 to 2.06 across HDSS sites). The poorest group had consistently higher death rates in communicable, maternal, neonatal, and nutritional conditions (rate ratios ranged 1.34–4.05) and for non-communicable diseases in several sites (1.14–1.93). The disparities in mortality between 5–8 deprivation groups and 0–2 deprivation groups led to lower life expectancy in the higher-deprivation groups by six years in all sites and more than 10 years in five sites.

Conclusions: We show large disparities in mortality on the basis of socioeconomic status across seven HDSS in sub-Saharan Africa due to disparities in communicable disease mortality and from non-communicable diseases in some sites. Life expectancy gaps between socioeconomic groups within sites were similar to the gaps between high-income and lower-middle-income countries. Prevention and treatment efforts can benefit from understanding subpopulations facing higher mortality from specific conditions.

Heat shock factor 1 suppresses the HIV-induced inflammatory response by inhibiting nuclear factor-κB

The persistent inflammation aggravated by a disordered immune response is considered to be the major cause of CD4⁺ T cell depletion in lymphoid tissue, which impels the progression of AIDS. Here, we report that heat shock factor 1 (HSF1) works as an innate repressor of HIV-induced inflammation. The activation of HSF1 was found to accompany inflammation during HIV infection. Further research uncovered that HSF1 activation inhibited HIV-induced inflammation. In addition, HSF1 overexpression suppressed the inflammatory response induced by HIV, while HSF1 deficiency exacerbated that inflammation. Mechanistically, HSF1 was found to compete with nuclear factor-κB (NF-κB) in the nucleus. Generally, our report highlights that HSF1 is an important host factor in regulating HIV-induced inflammation and may work as a potential target for curing AIDS.

Risk Factors for Mortality among Adult HIV/AIDS Patients Following Antiretroviral Therapy in Southwestern Ethiopia: An Assessment through Survival Models

Introduction: Efforts have been made to reduce HIV/AIDS-related mortality by delivering antiretroviral therapy (ART) treatment. However, HIV patients in resource-poor settings are still dying, even if they are on ART treatment. This study aimed to explore the factors associated with HIV/AIDS-related mortality in Southwestern Ethiopia. Method: A non-concurrent retrospective cohort study which collected data from the clinical records of adult HIV/AIDS patients, who initiated ART treatment and were followed between January 2006 and December 2010, was conducted, to explore the factors associated with HIV/AIDS-related mortality at Jimma University Specialized Hospital (JUSH). Survival times (i.e., the time from the onset of ART treatment to the death or censoring) and different characteristics of patients were retrospectively examined. A best-fit model was chosen for the survival data, after the comparison between native semi-parametric Cox regression and parametric survival models (i.e., exponential, Weibull, and log-logistic). Result: A total of 456 HIV patients were included in the study, mostly females (312, 68.4%), with a median age of 30 years (inter-quartile range (IQR): 23–37 years). Estimated follow-up until December 2010 accounted for 1245 person-years at risk (PYAR) and resulted in 66 (14.5%) deaths and 390 censored individuals, representing a median survival time of 34.0 months ( IQR: 22.8–42.0 months). The overall mortality rate was 5.3/100 PYAR: 6.5/100 PYAR for males and 4.8/100 PYAR for females. The Weibull survival model was the best model for fitting the data (lowest AIC). The main factors associated with mortality were: baseline age (>35 years old, AHR = 3.8, 95% CI: 1.6–9.1), baseline weight (AHR = 0.93, 95% CI: 0.90–0.97), baseline WHO stage IV (AHR = 6.2, 95% CI: 2.2–14.2), and low adherence to ART treatment (AHR = 4.2, 95% CI: 2.5–7.1). Conclusion: An effective reduction in HIV/AIDS mortality could be achieved through timely ART treatment onset and maintaining high levels of treatment adherence.

Socio-economic differences in HIV/AIDS mortality in South Africa

OBJECTIVES

To quantify socio-economic differences in the risk of HIV/AIDS mortality in South Africa for different measures of socio-economic status.

METHODS

Systematic literature search in Web of Knowledge and PubMed. Measures of relative risk (RR) were pooled separately for education, income, assets score and employment status as measures of socio-economic status, using inverse-variance weighted DerSimonian-Laird random effects meta-analyses.

RESULTS

Ten studies were eligible for inclusion comprising over 175 000 participants and 6700 deaths. For income (RR 1.55, 95% confidence interval (CI) 1.15-2.09), assets score (RR 1.63, 95% CI 1.12-2.36) and employment status (RR 1.52, 95% CI 1.21-1.92), persons of low socio-economic status had an over 50% higher risk of dying from HIV/AIDS. The RR of 1.10 for education was not significant (95% CI 0.74-1.65).

CONCLUSIONS

Future research should identify effective strategies to reduce HIV/AIDS mortality and alleviate the consequences of HIV/AIDS deaths, particularly for poorer households.

The development of a localised HIV epidemic and the associated excess mortality burden in a rural area of South Africa

The human immunodeficiency virus (HIV) epidemic in South Africa rapidly developed into a major pandemic. Here we analyse the development of the epidemic in a rural area of the country. The data used were collected between 1992 and 2013 in a longitudinal population survey, the Agincourt Health and Demographic Surveillance Study, in the northeast of the country. Throughout the period of study mortality rates were similar in all villages, suggesting that there were multiple index cases evenly spread geographically. These were likely to have been returning migrant workers. For those aged below 39 years the HIV mortality rate was higher for women, above this age it was higher for men. This indicates the protective effect of greater access to HIV testing and treatment among older women. The recent convergence of mortality rates for Mozambicans and South Africans indicates that the former refugee population are being assimilated into the host community. More than 60% of the deaths occurring in this community between 1992 and 2013 could be attributed directly or indirectly to HIV. Recently there has been an increasing level of non-HIV mortality which has important implications for local healthcare provision. This study demonstrates how evidence from longitudinal analyses can support healthcare planning.

CD4 Cell Count: Declining Value for Antiretroviral Therapy Eligibility

Antiretroviral therapy (ART) policy for people living with human immunodeficiency virus (HIV) has historically been based on clinical indications, such as opportunistic infections and CD4 cell counts. Studies suggest that CD4 counts early in HIV infection do not predict relevant public health outcomes such as disease progression, mortality, and HIV transmission in people living with HIV. CD4 counts also vary widely within individuals and among populations, leading to imprecise measurements and arbitrary ART initiation. To capture the clinical and preventive benefits of treatment, the global HIV response now focuses on increasing HIV diagnosis and ART coverage. CD4 counts for ART initiation were necessary when medications were expensive and had severe side effects, and when the impact of early ART initiation was unclear. However, current evidence suggests that although CD4 counts may still play a role in guiding clinical care to start prophylaxis for opportunistic infections, CD4 counts should cease to be required for ART initiation.

Trends and determinants of survival for over 200 000 patients on antiretroviral treatment in the Botswana National Program: 2002-2013

Objectives:

To determine the incidence and risk factors of mortality for all HIV-infected patients receiving antiretroviral treatment at public and private healthcare facilities in the Botswana National HIV/AIDS Treatment Programme.

Design:

We studied routinely collected data from 226 030 patients enrolled in the Botswana National HIV/AIDS Treatment Programme from 2002 to 2013.

Methods:

A person-years (P-Y) approach was used to analyse all-cause mortality and follow-up rates for all HIV-infected individuals with documented antiretroviral therapy initiation dates. Marginal structural modelling was utilized to determine the effect of treatment on survival for those with documented drug regimens. Sensitivity analyses were performed to assess the robustness of our results.

Results:

Median follow-up time was 37 months (interquartile range 11–75). Mortality was highest during the first 3 months after treatment initiation at 11.79 (95% confidence interval 11.49–12.11) deaths per 100 P-Y, but dropped to 1.01 (95% confidence interval 0.98–1.04) deaths per 100 P-Y after the first year of treatment. Twelve-month mortality declined from 7 to 2% of initiates during 2002–2012. Tenofovir was associated with lower mortality than stavudine and zidovudine.

Conclusion:

The observed mortality rates have been declining over time; however, mortality in the first year, particularly first 3 months of antiretroviral treatment, remains a distinct problem. This analysis showed lower mortality with regimens containing tenofovir compared with zidovudine and stavudine. CD4⁺ cell count less than 100 cells/μl, older age and being male were associated with higher odds of mortality.

Predicting mortality rates: Comparison of an administrative predictive model (hospital standardized mortality ratio) with a physiological predictive model (Acute Physiology and Chronic Health Evaluation IV)--A cross-sectional study

INTRODUCTION

Direct comparison of mortality rates has limited value because most deaths are due to the disease process. Predicting the risk of death accurately remains a challenge.

METHODS

A cross-sectional study compared the expected mortality rate as calculated with an administrative model to a physiological model, Acute Physiology and Chronic Health Evaluation IV. The combined cohort and stratified samples (<0.1, 0.1-0.5, or >0.5 predicted mortality) were considered. A total of 47,982 patients were scored from 1 July 2013 to 30 June 2014, and 46,061 records were included in the analysis.

RESULTS

A moderate correlation was shown for the combined cohort (Pearson correlation index, 0.618; 95% confidence interval [CI], 0.380-0.779; R(2) = 0.38). A very good correlation for the less than 10% stratum (Pearson correlation index, 0.884; R(2) = 0.78; 95% CI, 0.79-0.937) and a moderate correlation for 0.1 to 0.5 predicted mortality rates (Pearson correlation index, 0.782; R(2) = 0.61; 95% CI, 0.623-0.879). There was no significant positive correlation for the greater than 50% predicted mortality stratum (Pearson correlation index, 0.087; R(2) = 0.007; 95% CI, -0.23 to 0.387).

CONCLUSION

At less than 0.1, the models are interchangeable, but in spite of a moderate correlation, greater than 0.1 hospital standardized mortality ratio cannot be used to predict mortality.