Background Prognostic models have been developed for HIV-1 infected patients who start combination antiretroviral therapy (ART) in high-income countries, but not for patients treated in sub-Saharan Africa. Methods We included 10,331 adult patients who started ART between 2004 and 2007 in ART scale-up programmes in Côte d’Ivoire, South Africa and Malawi. Data were analysed by intention-to-continue-treatment, ignoring treatment changes and interruptions. We used Weibull survival models to construct two prognostic models: one that included baseline CD4 count and one that did not, since in many African settings CD4 count is not routinely measured. Findings During the first year after starting ART, 912 (8.2%) patients died. Baseline CD4 cell count (adjusted hazard ratio 0.21 [95% CI 0.17–0.27] comparing ≥200 with <25 cells/μL), WHO clinical stage (3.45 [2.43–4.90] comparing stages III/IV with I/II), body weight (0.23 [0.18–0.30] comparing ≥60 with <45kg) and anaemia (0.27 [0.20–0.36] comparing none with severe) were strongly associated with mortality. Other independent risk factors were low total lymphocyte count, advanced age and male sex. The CD4 model included CD4 count, clinical stage, body weight, age and sex (160 risk strata). In the alternative model CD4 count was replaced by total lymphocyte count and degree of anaemia (288 risk strata). With the CD4 model the probability of death ranged from 0.9% (95% CI 0.6–1.4) in patients in the lowest risk stratum to 53% (44–62) in patients in the highest risk stratum. The corresponding probabilities for the total lymphocyte/haemoglobin model were 0.9% (0.5–1.4) and 60% (48–71). Interpretation Prognostic models based on the CD4 cell count, or total lymphocytes and haemoglobin provide similarly strong discrimination in predicting early mortality in patients starting ART in sub-Saharan Africa. These models are useful for counselling patients, planning health services and predicting outcomes at the population level.

Matthias Egger and colleagues present a nomogram and a web-based calculator to correct estimates of program-level mortality for loss to follow-up, for use in antiretroviral treatment programs.

Comparing mortality rates between patients starting HIV treatment and the general population in four African countries, Matthias Egger and colleagues find the gap decreases over time, especially with early treatment.

These data give new arguments to reinforce the hypothesis that, in this region, ART should be started before the CD4 cell count drops below 350 cells/mul. Further studies should assess whether patients with low BMI, low haemoglobin, high viral load or past history of tuberculosis should start ART earlier.

National Research Agency on AIDS and Viral Hepatitis (ANRS).