Abstract
BackgroundThough 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.MethodsThis retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15th 2006 and May 15th 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.ResultsThe 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).ConclusionsHigh 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.
Highlights
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
It is well established that ART reduces mortality and prevent opportunistic infection among HIV patients in high-income countries and in generalized epidemics in Africa, mortality rates and mortality determinants among ART-recipients in countries with concentrated epidemics
No previous systematic review has been done in Nepal, but it is needed to better understand the most important determinants of mortality among patients initiated on ART in order to identify those at the highest risk of preventable death
Summary
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. Nepal has a concentrated HIV epidemic with a low estimated HIV prevalence of 0.30% among adults (15–49 years) in the general population but over 5-fold higher rates among populations at higher risk including male labour migrants ( to India where they often visit sex workers), men who have sex with men, female sex workers, people who inject drugs [7,9]. No previous systematic review has been done in Nepal, but it is needed to better understand the most important determinants of mortality among patients initiated on ART in order to identify those at the highest risk of preventable death. This cohort study explores the mortality rates and determinants among all known ART patients in one of the five development regions of Nepal, the Far-western region, in a thorough retrospective assessment including the most recent available data since the start of ART in this area, i.e. from 2006 to 2011
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