Abstract
BackgroundThe roll out of antiretroviral therapy (ART) in Sub-Saharan Africa led to a decrease in mortality. Few studies have documented the causes of deaths among patients on long term antiretroviral therapy in Sub-Saharan Africa. Our objective was to describe the causes of death among patients on long term ART in Sub-Saharan Africa.MethodsWe used data from a prospective cohort of ART naïve patients receiving care and treatment at the Infectious Diseases Institute in Kampala, Uganda. Patients were followed up for 10 years. All deaths were recorded and possible causes established using verbal autopsy. Deaths were grouped as HIV-related (ART toxicities, any opportunistic infections (OIs) and HIV-related malignancies) and non-HIV related deaths while some remained unknown. We used Kaplan Meier survival methods to estimate cumulative incidence and rates of mortality for all causes of death.ResultsOf the 559, (386, 69%) were female, median age 36 years (IQR: 21–44), 89% had WHO clinical stages 3 and 4, and median CD4 count at ART initiation was 98 cells/μL (IQR: 21–163). A total of 127 (22.7%) deaths occurred in 10 years. The HIV related causes of death (n = 70) included the following; Tuberculosis 17 (24.3%), Cryptococcal meningitis 10 (15.7%), Kaposi’s Sarcoma 7(10%), HIV related toxicity 6 (8.6%), HIV related anemia 5(7.1%), Pneumocystis carinii Pneumonia (PCP) 5 (7.1%), HIV related chronic diarrhea 4 (5.7%), Non-Hodgkin Lymphoma 3 (4.3%), Herpes Zoster 2 (2.8%), other 10 (14.3%). The non-HIV related causes of death (n = 20) included non-communicable diseases (diabetes, hypertension, stroke) 6 (30%), malaria 3 (15%), pregnancy-related death 2 (10%), cervical cancer 2 (10%), trauma 1(5%) and others 6 (30%).ConclusionDespite the higher rates of deaths from OIs in the early years of ART initiation, we observed an emergence of non-HIV related causes of morbidity and mortality. It is recommended that HIV programs in resource-limited settings start planning for screening and treatment of non-communicable diseases.
Highlights
The roll out of antiretroviral therapy (ART) in Sub-Saharan Africa led to a decrease in mortality
A total of 559 Human Immune deficiency Virus (HIV) positive patients were included in the analysis, of whom majority were female (386, 69%) with median age of 36 years (interquartile range (IQR): 21– 44), 89% were in WHO clinical stages 3 and 4 (89%), with a median CD4 count of 98 cells/μL (IQR: 21–163)
A total of 20 persons were diagnosed with Cryptococcal meningitis and of these 10 died, yield a Discussion Our study describes the causes of death overtime up to 10 years of follow up among HIV positive patients in Sub-Saharan Africa
Summary
The roll out of antiretroviral therapy (ART) in Sub-Saharan Africa led to a decrease in mortality. Few studies have documented the causes of deaths among patients on long term antiretroviral therapy in Sub-Saharan Africa. Our objective was to describe the causes of death among patients on long term ART in Sub-Saharan Africa. The UNAIDS 2016 global report shows gains in treatment of HIV positive persons were responsible for a 26% decline in AIDS-related deaths from an estimate of 1.5 million [1.3 million – 1.7million] persons. The success of ART roll out in sub-Saharan Africa has been undermined by high mortality, especially in the first year after starting ART [8]. There is limited information on the specific causes of death among patients on long term ART in Sub-Saharan Africa. We previously described mortality in only the first three years in a research cohort of patients started on treatment during the initial roll out of ART. Our results showed that the most common causes of early mortality were tuberculosis and Cryptococcal meningitis [10]
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