Abstract
BackgroundHigh early mortality rate among HIV infected patients following initiation of antiretroviral therapy (ART) in resource limited settings may indicate high pre-treatment mortality among ART-eligible patients. There is dearth of data on pre-treatment mortality in ART programmes in sub-Sahara Africa. This study aims to determine pre-treatment mortality rate and predictors of pre-treatment mortality among ART-eligible adult patients in a West Africa clinic-based cohort.MethodsAll HIV-infected patients aged 15 years or older eligible for ART between June 2004 and September 2009 were included in the analysis. Assessment for eligibility was based on the Gambia ART guideline. Survival following ART-eligibility was determined by Kaplan-Meier estimates and predictors of pre-treatment mortality determined by Cox proportional hazard models.ResultOverall, 790 patients were assessed as eligible for ART based on their clinical and/or immunological status among whom 510 (64.6%) started treatment, 26 (3.3%) requested transfer to another health facility, 136 (17.2%) and 118 (14.9%) were lost to follow-up and died respectively without starting ART. ART-eligible patients who died or were lost to follow-up were more likely to be male or to have a CD4 T-cell count < 100 cells/μL, while patients in WHO clinical stage 3 or 4 were more likely to die without starting treatment. The overall pre-treatment mortality rate was 21.9 deaths per 100 person-years (95% CI 18.3 - 26.2) and the rate for the composite end point of death or loss to follow-up was 47.1 per 100 person-years (95% CI 41.6 - 53.2). Independent predictors of pre-treatment mortality were CD4 T-cell count <100 cells/μL (adjusted Hazard ratio [AHR] 3.71; 95%CI 2.54 - 5.41) and WHO stage 3 or 4 disease (AHR 1.91; 95% CI 1.12 - 3.23). Forty percent of ART-eligible patients lost to follow-up seen alive at field visit cited difficulty with the requirement of disclosing their HIV status as reason for not starting ART.ConclusionApproximately one third of ART-eligible patients did not start ART and pre-treatment mortality rate was found high among HIV infected patients in our cohort. CD4 T-cell count <100 cells/μL is the strongest independent predictor of pre-treatment mortality. The requirement to disclose HIV status as part of ART preparation counselling constitutes a huge barrier for eligible patients to access treatment.
Highlights
It is estimated that nearly 37% of people eligible for Antiretroviral therapy (ART) in sub-Sahara Africa were able to access the life saving medicines in 2009 [1]
Baseline characteristics Of the 2645 HIV-infected adult patients seen at the Medical Research Council (MRC) HIV clinic between June 2004 and September 2009, 790 were found to be eligible for antiretroviral therapy (ART) and were enrolled for ART preparation counselling (Figure 1)
ART-eligible patients who were lost to follow-up or died before starting treatment were significantly more likely to be male or have a lower median CD4 T cell count, while patients in WHO stage 3 or 4 are more likely to die before starting treatment
Summary
It is estimated that nearly 37% of people eligible for Antiretroviral therapy (ART) in sub-Sahara Africa were able to access the life saving medicines in 2009 [1] This increase in availability of ART has, without doubt, impacted positively on the prognosis of HIV/AIDS patients in sub-Sahara Africa with reductions in mortality rate when compared with previous reports in untreated patients [2]. There are few data on mortality during the interval between enrolment of ART-eligible HIV-infected adult patients into ART programmes and initiation of treatment in sub-Sahara Africa, and none from the West African region. Information on pre-treatment mortality of ART-eligible HIV infected patients is not routinely collected in most ART programmes in Africa as programme evaluation is most often based on number of patients who start and remain on treatment. This study aims to determine pre-treatment mortality rate and predictors of pre-treatment mortality among ART-eligible adult patients in a West Africa clinic-based cohort
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