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. 2014 May 7;1(1):ofu011.
doi: 10.1093/ofid/ofu011. eCollection 2014 Mar.

High Mortality Among Human Immunodeficiency Virus (HIV)-Infected Individuals Before Accessing or Linking to HIV Care: A Missing Outcome in the Cascade of Care?

Hartmut B Krentz  1 , Judy MacDonald  2 , M John Gill  1
Affiliations

High Mortality Among Human Immunodeficiency Virus (HIV)-Infected Individuals Before Accessing or Linking to HIV Care: A Missing Outcome in the Cascade of Care?

Hartmut B Krentz et al. Open Forum Infect Dis. .

Abstract

Background: The "cascade of care" displays the proportion of individuals who are infected with human immunodeficiency virus (HIV), diagnosed, linked, retained, on antiretroviral treatment, and HIV suppressed. We examined the implications of including death in the use of this cascade for program and public health performance metrics.

Methods: Individuals newly diagnosed with HIV and living in Calgary between 2006 and 2013 were included. Through linkage with Public Health and death registries, the deaths (ie, all-cause mortality) and their distribution within the cascade were determined. Mortality rates are reported per 100 person-years.

Results: Estimated new HIV infections were 680 (543 confirmed and 137 unknown cases). Forty-three individuals, after diagnosis, were never referred for HIV care. Despite referral(s), 88 individuals (18%) never attended the clinic for HIV care. Of individuals retained in care, 87% received antiretroviral therapy and 76% achieved viral suppression. Thirty-six deaths were reported (mortality rate, 1.50/100 person-years). One diagnosis was made posthumously. Deaths (20 of 35; 57%) occurred for individuals linked but not retained in care (6.93/100 person-years), and 70% were HIV-related. Mortality rate for patients in care was 0.79/100 person-years. Retained patients with detectable viremia had a death rate of 2.49/100, which contrasted with 0.28/100 person-years in those with suppressed viremia. Eight of these 15 deaths (53%) were HIV-related.

Conclusions: Over half of deaths occurred in those referred but not effectively linked or retained in HIV care, and these cases may be easily overlooked in standard HIV mortality studies. Inclusion of deaths into the cascade may further enhance its value as a public health metric.

Keywords: Canada; HIV/AIDS; accessing care; cascade of care; mortality.

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Figures

Figure 1.
Figure 1.
Cascade of care for all new human immunodeficiency virus (HIV) infections (estimated and known cases = 680) in the Alberta Health Services, Calgary region from January 1, 2006 to January 1, 2013. Placement and proportions of all-cause deaths (N = 36) are shown in red.
See this image and copyright information in PMC

References

    1. Gardner EM, McLees MP, Stiener JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:793–800. - PMC - PubMed
    1. Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement in HIV care in the United States: from cascade to continuum to control. Clin Infect Dis. 2013;57:1164–71. - PubMed
    1. Nosyk B, Montaner JS, Colley G, et al. The cascade of HIV care in British Columbia, Canada, 1996–2011: a population-based retrospective cohort study. Lancet Infect Dis. 2014;4:40–9. - PMC - PubMed
    1. Tobias C, Cunningham WE, Cunningham CO, Pounds MB. Making the connection: the importance of engagement and retention in HIV medical care. AIDS Patient Care STDS. 2007;21(Suppl 1):S53–8. - PubMed
    1. Kilmarx PH, Mutasa-Apollo T. Patching a leaky pipe: the cascade of HIV care. Curr Opin HIV AIDS. 2013;8:59–64. - PubMed