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Comparative Study
. 2009 Apr 28;6(4):e1000066.
doi: 10.1371/journal.pmed.1000066. Epub 2009 Apr 28.

Mortality of HIV-infected patients starting antiretroviral therapy in sub-Saharan Africa: comparison with HIV-unrelated mortality

Martin W G Brinkhof  1 , Andrew Boulle, Ralf Weigel, Eugène Messou, Colin Mathers, Catherine Orrell, François Dabis, Margaret Pascoe, Matthias Egger; International Epidemiological Databases to Evaluate AIDS (IeDEA)
Affiliations
Comparative Study

Mortality of HIV-infected patients starting antiretroviral therapy in sub-Saharan Africa: comparison with HIV-unrelated mortality

Martin W G Brinkhof et al. PLoS Med. .

Abstract

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 Côte 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/microl 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/microl 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/microl 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.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. All-cause mortality for the year 2004 as the total of HIV-related (red area) and HIV-unrelated mortality (white area) by 5-y age group in Côte d'Ivoire, Malawi, South Africa, and Zimbabwe.
Age groups are indicated by the lower age, e.g., age group 15 indicating age 15–19 y, age group 20 indicating age 20–24 y, and so forth. Data from the Global Burden of Disease Study ,.
Figure 2
Figure 2. Distribution of excess mortality over the first 2 y of ART in patients starting ART in five treatment programmes in sub-Saharan Africa.
See this image and copyright information in PMC

References

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