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. 2025 Apr 18:49:e36.
doi: 10.26633/RPSP.2025.36. eCollection 2025.

Predictors of mortality among individuals with advanced HIV disease in a contemporary Brazilian cohort

Nicole Reis  1 , Omar Sued  2 , Tarsila Vieceli  3 , Diego R Falci  3 , Larissa R Silva  1 , Pedro M Fonseca  4 , Renata B A Soares  5 , Cassia S M Godoy  5 , Marineide G Melo  4 , Nayla A Hatem  1 , Ana C G Castelo  1 , Freddy Perez  2 , Alessandro C Pasqualotto  1
Affiliations

Predictors of mortality among individuals with advanced HIV disease in a contemporary Brazilian cohort

Nicole Reis et al. Rev Panam Salud Publica. .

Abstract
in English, Spanish, Portuguese

Objective: To identify clinical characteristics and risk factors associated with mortality, with a focus on opportunistic infections (OIs), in patients with advanced HIV in Brazil.

Methods: A prospective cohort study was conducted in five Brazilian tertiary hospitals, including 419 adults with advanced HIV. Baseline demographic and clinical data were collected during hospital admission, and participants were screened for tuberculosis, cryptococcosis, and histoplasmosis using rapid diagnostic tests. Participants were followed for 90 days to assess mortality, with causes of death classified using the Coding of Death in HIV (CoDe) protocol. Statistical analysis identified the variables associated with mortality.

Results: The median CD4 count was 66 cells/mm³, and the median HIV viral load was 104 887 copies/mL. After 90 days, 18.1% of participants had died. ART-naive status, mental confusion, anemia, and elevated creatinine levels were strongly associated with mortality. OIs were diagnosed in 45.6% of participants, with severe histoplasmosis and cryptococcal meningitis significantly increasing the risk of mortality. Social determinants, such as sex, race, gender, and education level, did not have a significant impact on mortality, but socio-economic factors influenced health care access.

Conclusion: Early HIV diagnosis and continuous ART are essential to reduce mortality. Public health strategies should prioritize improving HIV testing, treatment adherence, and addressing social disparities to mitigate health care inequalities.

Objetivo: Determinar las características clínicas y los factores de riesgo asociados a la mortalidad, en especial por lo que respecta a las infecciones oportunistas, en pacientes con infección avanzada por el virus de la inmunodeficiencia humana (VIH) en Brasil.

Método: Se realizó un estudio prospectivo de cohorte en cinco hospitales terciarios brasileños, con la inclusión de 419 personas adultas con infección avanzada por el VIH. Se recopilaron los datos demográficos y clínicos iniciales durante el ingreso hospitalario, y se realizó un tamizaje para la detección de tuberculosis, criptococosis e histoplasmosis en todos los participantes mediante pruebas de diagnóstico rápido. Se llevó a cabo un seguimiento durante 90 días para evaluar la mortalidad; se clasificaron las causas de muerte mediante el protocolo de codificación de causas de muerte en la infección por el VIH (CoDe). El análisis estadístico determinó las variables asociadas a la mortalidad.

Resultados: La mediana del recuento de linfocitos CD4 fue de 66 linfocitos/mm3 y la mediana de la carga viral del VIH fue de 104 887 copias/ml. Después de 90 días, el 18,1% de los participantes había fallecido. Se observó una asociación intensa de los siguientes factores con la mortalidad: el hecho de no haber recibido ningún tratamiento antirretroviral anteriormente, la confusión mental, la anemia y los niveles elevados de creatinina. En el 45,6% de los participantes se diagnosticaron infecciones oportunistas, y la meningitis criptocócica y la histoplasmosis grave se asociaron a un aumento significativo de la mortalidad. Los determinantes sociales, como el sexo, la etnia, el género y el nivel de estudios, no tuvieron un impacto significativo en la mortalidad, pero los factores socioeconómicos influyeron en el acceso a la atención de salud.

Conclusiones: El diagnóstico temprano de la infección por el VIH y el tratamiento antirretroviral continuado son esenciales para reducir la mortalidad. Las estrategias de salud pública deben priorizar la mejora de las pruebas de detección del VIH, la adhesión al tratamiento y el abordaje de las desigualdades sociales para mitigar las inequidades en la atención de salud.

Objetivo: Identificar as características clínicas e os fatores de risco associados à mortalidade, com ênfase nas infecções oportunistas, em pacientes com doença avançada pelo HIV no Brasil.

Métodos: Um estudo de coorte prospectivo foi realizado em cinco hospitais terciários brasileiros, incluindo 419 adultos com doença avançada pelo HIV. Os dados demográficos e clínicos para a linha de base foram coletados durante a internação hospitalar dos participantes, que foram rastreados para tuberculose, criptococose e histoplasmose por meio de testes de diagnóstico rápido. Os participantes foram acompanhados por 90 dias para avaliar a mortalidade, e as causas de morte foram classificadas segundo o protocolo Coding Causes of Death in HIV (CoDe). A análise estatística identificou as variáveis associadas à mortalidade.

Resultados: A mediana da contagem de linfócitos T CD4+ foi de 66 células/mm³, e a mediana da carga viral de HIV foi de 104 887 cópias/mL. Após 90 dias, 18,1% dos participantes tinham falecido. Ser virgem de terapia antirretroviral (TARV) ou ter confusão mental, anemia ou níveis elevados de creatinina foram fatores fortemente associados à mortalidade. Foram diagnosticadas infecções oportunistas em 45,6% dos participantes, e quadros graves de histoplasmose e meningite criptocócica aumentaram significativamente o risco de morte. Determinantes sociais, como sexo, raça, gênero e escolaridade, não tiveram um impacto significativo na mortalidade, mas fatores socioeconômicos tiveram influência sobre o acesso à atenção à saúde.

Conclusão: O diagnóstico precoce do HIV e a TARV ininterrupta são essenciais para reduzir a mortalidade. As estratégias de saúde pública devem priorizar o aprimoramento da testagem de HIV, a adesão ao tratamento e a abordagem das disparidades sociais de modo a mitigar as desigualdades na atenção à saúde.

Keywords: AIDS-related opportunistic infections; HIV; mortality; point-of-care testing; risk factors.

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Conflict of interest statement

Conflicts of interests. Dr. Pasqualotto has received research grants from Gilead, Pfizer, MSD, and IMMY. He has consulted and/or given paid talks on behalf of Gilead, Knight (United Medical), Pfizer, MSD, PAHO, IMMY, Mundipharma, Sandoz, Biomérrieux, Teva, Astra-Zeneca, and Astellas Pharma. Dr. Falci received research grants and consulting fees from Gilead Sciences and GSK. He has consulted and/or given paid talks on behalf of Knight Therapeutics, Mundipharma, Sandoz, Pfizer, and GSK, and received nonfinancial research support from Immy.

Figures

FIGURE 1.
FIGURE 1.. Probability of survival according to CD4 intervals
FIGURE 2.
FIGURE 2.. Probability of survival according to each opportunistic infection
See this image and copyright information in PMC

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