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Determinants of Mortality among HIV-infected Individuals Receiving Home-based ART in Rural Uganda
David Moore*1,2, David Moore*1,2, C Yiannoutsos3, B Musick3, R Downing1, W Were1, R Degerman1, L Alexander1, and J Mermin1
1Global AIDS Prgm, CDC Uganda, Entebbe; 2BC Ctr for Excellence in HIV/AIDS, Vancouver, Canada; and 3Indiana Univ Sch of Med, Indianapolis, US
Background: Mortality among HIV-infected individuals
initiating ART in Sub-Saharan Africa is higher than in industrialized
countries. The ability of programs in Africa
to design specific interventions to prevent these deaths is limited by a paucity
of data on specific clinical conditions that are associated with mortality while
taking ART in African settings.
Methods: We examined data from participants aged
≥18 years in the Home-Based AIDS Care project in Tororo, Uganda,
to describe mortality rates over time and to determine clinical conditions
associated with death. Survival analysis was used to examine variables at
baseline and in follow-up that were associated with mortality while taking ART.
Results: A total of 1120 subjects initiated ART (73%
women). Median CD4 cell count at initiation of ART was 127
cells/µL, median hemoglobin was 11.3 g/dL, median
body mass index was 19.7 kg/m2, and 8% of subjects had WHO stage IV
disease. Subjects were followed for a median of 2.0 years. Cumulative mortality
was 3.3% during the first 3 months, 5.1% at 6 months, 7.5% at 12 months, 8.6% at
18 months, and 9.3% at 24 months after ART initiation. Tuberculosis (TB) was
the most common opportunistic infection associated with death (21% of deaths),
followed by cryptococcal disease (11%), candidiasis (11%), Pneumocystis jiroveci pneumonia (9%), and Kaposi’s sarcoma (6%). In
41.5% of deaths, no specific clinical condition was identified and 7% of deaths
had ≥2 diseases associated with death. Baseline CD4 cell counts (HR 1.006,
95%CI 1.003 to 1.008), body mass index <18 kg/m2 (HR 2.1, 95%CI 1.3
to 3.2), and hemoglobin <10 g/dL (HR 2.6, 95%CI 1.7
to 3.9) were the most important predictors of death in the first 6 months of
ART. Adherence to therapy of ≤90% was strongly associated with death in
adjusted models and the strength of the association increased from HR 3.3 in
the first 6 months (p <0.001)
after ART initiation to HR 7.4 after 6 months (p <0.001).
Conclusions: Strongly associated with mortality while
receiving ART are conditions that can be remedied—such as low body mass index and
anemia—or prevented—such as TB, candidiasis, and cryptococcal disease. These conditions should be addressed
through interventions, such as food supplementation, aggressive treatment of
anemia, and specific preventive therapy. Adherence to therapy assumes greater
importance with increasing time on ART.
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