Estimation of mortality among HIV-infected people on antiretroviral treatment in east Africa: a sampling based approach in an observational, multisite, cohort study (original) (raw)
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The lancet HIV, 2015
Mortality after initiation of antiretroviral treatment (ART) among HIV-infected patients in resource limited settings is a critical measure of the effectiveness and comparative effectiveness of the global public health response. Unknown outcomes due to high loss to follow-up (LTFU) preclude accurate accounting of deaths and limit our understanding of effectiveness. We evaluated in HIV-infected adults on ART in 14 clinics in five settings in Kenya, Uganda and Tanzania using a sampling-based approach in which we intensively traced a random sample of lost patients (> 90 days late for last scheduled visit) and incorporated their vital status outcomes into analyses of the entire clinic population through probability-weighted survival analyses. We followed 34,277 adults on ART from Mbarara and Kampala, Uganda; Eldoret and Kisumu, Kenya; and Morogoro, Tanzania. The median age was 35 years, 34% were men, and median pre-therapy CD4 count was 154 cells/μl. Overall 5,780 (17%) were LTFU, 99...
Tropical Medicine & International Health, 2010
Objective To date, data regarding the determinants of mortality in HIV-infected patients starting antiretroviral therapy (ART) in Africa have been primarily derived from routine clinical care settings practicing the public health approach. Losses to follow-up, however, are high in these settings and may lead to bias in understanding the determinants of mortality.Methods We evaluated HIV-infected adults initiating ART between January 1, 2004 and September 30th, 2007 in an ART clinic in southwestern Uganda. Clinical and demographic characteristics were obtained through routine clinical care. In evaluating determinants of mortality, a ‘naïve’ analysis used only deaths known through routine processes. A ‘sample-corrected’ approach incorporated, through probability weights, outcomes from a representative sample of patients lost to follow-up whose vital status was ascertained through tracking in the community.Results In 3,628 patients followed for up to 3.75 years after ART initiation, the ‘naïve’ approach identified male sex and lower pre-ART CD4 count as independent determinants of mortality. The ‘sample-corrected’ approach found lower pre-ART CD4 count, older age, lower weight and calendar year of ART initiation, but not male sex, to be independent determinants of mortality.Conclusions Analyses to identify determinants of mortality in HIV-infected patients on ART in Africa that do not account for losses to follow-up can identify spurious associations and miss actual relationships – both with the potential to mislead public health efforts. A sampling-based approach to account for losses to follow-up represents a feasible and potentially scalable method to strengthen the evidence available for implementation of ART delivery in Africa.
Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa
PloS one, 2010
Evaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up. Treatment-naïve patients starting combination ART in five programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell co...
PLoS Medicine, 2009
Background: Mortality in HIV-infected patients who have access to highly active antiretroviral therapy (ART) has declined in sub-Saharan Africa, but it is unclear how mortality compares to the non-HIV-infected population. We compared mortality rates observed in HIV-1-infected patients starting ART with non-HIV-related background mortality in four countries in sub-Saharan Africa. Methods and Findings: Patients enrolled in antiretroviral treatment programmes in Cô te d'Ivoire, Malawi, South Africa, and Zimbabwe were included. We calculated excess mortality rates and standardised mortality ratios (SMRs) with 95% confidence intervals (CIs). Expected numbers of deaths were obtained using estimates of age-, sex-, and country-specific, HIV-unrelated, mortality rates from the Global Burden of Disease project. Among 13,249 eligible patients 1,177 deaths were recorded during 14,695 person-years of follow-up. The median age was 34 y, 8,831 (67%) patients were female, and 10,811 of 12,720 patients (85%) with information on clinical stage had advanced disease when starting ART. The excess mortality rate was 17.5 (95% CI 14.5-21.1) per 100 person-years SMR in patients who started ART with a CD4 cell count of less than 25 cells/ml and World Health Organization (WHO) stage III/IV, compared to 1.00 (0.55-1.81) per 100 person-years in patients who started with 200 cells/ml or above with WHO stage I/II. The corresponding SMRs were 47.1 (39.1-56.6) and 3.44 (1.91-6.17). Among patients who started ART with 200 cells/ml or above in WHO stage I/II and survived the first year of ART, the excess mortality rate was 0.27 (0.08-0.94) per 100 person-years and the SMR was 1.14 (0.47-2.77). Conclusions: Mortality of HIV-infected patients treated with combination ART in sub-Saharan Africa continues to be higher than in the general population, but for some patients excess mortality is moderate and reaches that of the general population in the second year of ART. Much of the excess mortality might be prevented by timely initiation of ART.
AIDS Research and Therapy, 2011
Background There have been few reports of long-term survival of HIV-infected patients on antiretroviral therapy (ART) in Africa managed under near normal health service conditions. Methods Participants starting ART between February 2005 and December 2006 in The AIDS Support (TASO) clinic in Jinja, Uganda, were enrolled into a cluster-randomised trial of home versus facility-based care and followed up to January 2009. The trial was integrated into normal service delivery with patients managed by TASO staff according to national guidelines. Rates of survival, virological failure, hospital admissions and CD4 count over time were similar between the two arms. Data for the present analysis were analysed using Cox regression analyses. Results 1453 subjects were enrolled with baseline median count of 108 cells/μl. Over time, 119 (8%) withdrew and 34 (2%) were lost to follow-up. 197/1453 (14%) died. Mortality rates (95% CI) per 100 person-years were 11.8 (10.1, 13.8) deaths in the first yea...
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2015
In resource-limited settings, early mortality on antiretroviral therapy (ART) is approximately 10%; yet, it is unclear how much of that mortality occurs in care or after lost to follow-up. We assessed mortality rates and predictors of death among 12,222 nonpregnant ART-naive adults initiating first-line ART between April 2004 and May 2012 in South Africa, stratified by person-years in care and lost. We found 14.6% of patients died and being lost accounted for a minority of deaths across multiple definitions of loss (population attributable-risk percent ranged from 10.4% to 42.5%). Although mortality rates in patients lost were much higher than in care, most ART-related mortality occurred on treatment.
PLoS Medicine, 2011
Background: The World Health Organization estimates that in sub-Saharan Africa about 4 million HIV-infected patients had started antiretroviral therapy (ART) by the end of 2008. Loss of patients to follow-up and care is an important problem for treatment programmes in this region. As mortality is high in these patients compared to patients remaining in care, ART programmes with high rates of loss to follow-up may substantially underestimate mortality of all patients starting ART.