Reduction in Early Mortality on Antiretroviral Therapy for Adults in Rural South Africa Since Change in CD4+ Cell Count Eligibility Criteria

Lessells, Richard J; Mutevedzi, Portia; Iwuji, Collins; Newell, Marie‐Louise

doi:10.1097/qai.0b013e31829ceb14

Cited by 35 publications

(31 citation statements)

References 31 publications

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“…Antiretroviral therapy was made available to patients with CD4 counts less than 200 cells per μL through public-sector primary health-care clinics in September, 2004. Treatment eligibility was extended to patients with CD4 counts of less than 350 cells per μL for pregnant women and patients with active tuberculosis in April, 2010, and then for all adult patients in August, 2011 27 . Antiretroviral therapy coverage of all HIV-infected people in the study area rose from 0% in 2004 to 31% in 2011 26 …”

Section: Methodsmentioning

confidence: 99%

Use of antiretroviral therapy in households and risk of HIV acquisition in rural KwaZulu-Natal, South Africa, 2004–12: a prospective cohort study

Vandormael¹,

Newell²,

Bärnighausen³

et al. 2014

The Lancet Global Health

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SummaryBackgroundStudies of HIV-serodiscordant couples in stable sexual relationships have provided convincing evidence that antiretroviral therapy can prevent the transmission of HIV. We aimed to quantify the preventive effect of a public-sector HIV treatment and care programme based in a community with poor knowledge and disclosure of HIV status, frequent migration, late marriage, and multiple partnerships. Specifically, we assessed whether an individual's hazard of HIV acquisition was associated with antiretroviral therapy coverage among household members of the opposite sex.MethodsIn this prospective cohort study, we linked patients' records from a public-sector HIV treatment programme in rural KwaZulu-Natal, South Africa, with population-based HIV surveillance data collected between 2004 and 2012. We used information about coresidence to construct estimates of HIV prevalence and antiretroviral therapy coverage for each household. We then regressed the time to HIV seroconversion for 14 505 individuals, who were HIV-uninfected at baseline and individually followed up over time regarding their HIV status, on opposite-sex household antiretroviral therapy coverage, controlling for household HIV prevalence and a range of other potential confounders.Findings2037 individual HIV seroconversions were recorded during 54 845 person-years of follow-up. For each increase of ten percentage points in opposite-sex household antiretroviral therapy coverage, the HIV acquisition hazard was reduced by 6% (95% CI 2–9), after controlling for other factors. This effect size translates into large reductions in HIV acquisition hazards when household antiretroviral therapy coverage is substantially increased. For example, an increase of 50 percentage points in household antiretroviral therapy coverage (eg, from 20% to 70%) reduced the hazard of HIV acquisition by 26% (95% CI 9–39).InterpretationOur findings provide further evidence that antiretroviral therapy significantly reduces the risk of onward transmission of HIV in a real-world setting in sub-Saharan Africa. Awareness that antiretroviral therapy can prevent transmission to coresident sexual partners could be a powerful motivator for HIV testing and antiretroviral treatment uptake, retention, and adherence.FundingWellcome Trust and National Institute of Child Health and Human Development (US National Institutes of Health).

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Section: Methodsmentioning

confidence: 99%

Use of antiretroviral therapy in households and risk of HIV acquisition in rural KwaZulu-Natal, South Africa, 2004–12: a prospective cohort study

Vandormael¹,

Newell²,

Bärnighausen³

et al. 2014

The Lancet Global Health

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“…In our study, the main causes of clinical deterioration in patients were TB, PCP, CNS complications, malignant tumors, sepsis, and decompensated liver cirrhosis. Clinicians should strive to diagnose HIV and initiate ART earlier, which have been shown to potentially decrease short-term mortality by 46% (29).…”

Section: Discussionmentioning

confidence: 99%

“…Active TB among HIV-infected patients, even if successfully treated, seems to increase the number of deaths (9). Recent changes made in the eligibility criteria for receiving ART, using a higher CD4+ T-cell count cut-off, have resulted in a significant reduction in early mortality rates in South Africa (10). However, patients in China usually do not undergo HIV testing before contracting opportunistic infections (OIs).…”

Section: Introductionmentioning

confidence: 99%

Baseline Factors Associated with Mortality within Six Months after Admission among Hospitalized HIV-1 Patients in Shenyang, China

et al. 2014

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Objective Short-term mortality rates remain high among critically ill human immunodeficiency virus-1 (HIV-1) patients though long-term mortality rates have dropped. Baseline risk factors for short-term mortality have not yet been determined in China. In this paper, we herein describe clinical characteristics, laboratory findings, causes of clinical deterioration, and risk factors associated with mortality among HIV-1 patients within six months after hospital admission. Methods We carried out a prospective study of hospitalized patients in advanced stages of HIV infection. These patients started antiretroviral therapy three or four weeks after admission. Follow-up was conducted for a period of six months. We used a multivariate logistic-regression analysis to identify risk factors associated with mortality. Results A total of 141 patients met our inclusion criteria. The mean age was 41 years. Fever and weight loss were the most common clinical manifestations of advanced HIV disease. Oral candidiasis, tuberculosis, cytomegaloviremia, and pneumocystis pneumonia were the most common opportunistic infections. Significantly decreased CD4+ T-cell counts, hypoalbuminemia, anemia, hyponatremia, as well as elevated C-reactive protein (CRP) and glutamic alanine transaminase levels were common laboratory test abnormalities. The mortality rate was 21.3%. The patients who died were more likely than the survivors to have low CD4+ Tcell counts as well as low creatinine, hemoglobin, albumin, and serum sodium levels while also having longer intervals of fever and higher CRP levels. A multivariate analysis demonstrated that the independent risk factors for mortality were active tuberculosis [odds ratio (OR): 2.681; 95% confidence interval (CI), p=0.049], hyponatremia (OR: 3.027; 95% CI, p=0.015), and being at clinical stage 4 (as defined by the World Health Organization) (OR: 9.492; 95% CI, 1.200-75.065; p=0.033) within the first six months of admission. Conclusion Special consideration should be given to patients who have active tuberculosis, are at clinical stage 4, and present with hyponatremia upon admission as these were found to be important factors associated with mortality within six months of hospital admission in HIV-1 patients.

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“…As of the end of 2013, some 11.7 million adults and children were estimated to be on ART 1 , representing almost two thirds of those eligible for ART under current guidelines 2 . Recent studies have observed large reductions in mortality and corresponding increases in life expectancy in some of the hardest hit countries and populations 3,4 .…”

Section: Introductionmentioning

confidence: 99%

Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries

Fox

Rosen

2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

284

247

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Background We previously published systematic reviews of retention in care after antiretroviral therapy initiation among general adult populations in sub-Saharan Africa. We estimated 36-month retention at 73% for publications from 2007–2010. This report extends the review to cover 2008–2013 and expands it to all low- and middle-income countries. Methods We searched PubMed, Embase, Cochrane Register, and ISI Web of Science from January 1, 2008 to December 31, 2013 and abstracts from AIDS and IAS from 2008–2013. We estimated retention across cohorts using simple averages and interpolated missing times through the last time reported. We estimated all-cause attrition (death, loss to follow-up) for patients receiving first-line ART in routine settings in low- and middle-income countries. Results We found 123 papers and abstracts reporting retention for 154 patient cohorts and 1,554,773 patients in 42 countries. Overall, 43% of all patients not retained were known to have died. Unweighted averages of reported retention was 78%, 71% and 69% at 12, 24, and 36 months after treatment initiation, respectively. We estimated 36-month retention at 65% in Africa, 80% in Asia, and 64% in Latin America and the Caribbean. From lifetable analysis, we estimated retention at 12, 24, 36, 48 and 60 months at 83%, 74%, 68%, 64% and 60%, respectively. Conclusions Retention at 36 months on treatment averages 65–70%. There are several important gaps in the evidence-base, which could be filled by further research, especially in terms of geographic coverage and duration of follow-up.

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Reduction in Early Mortality on Antiretroviral Therapy for Adults in Rural South Africa Since Change in CD4+ Cell Count Eligibility Criteria

Abstract: Supplemental Digital Content is Available in the Text.

Cited by 35 publications

References 31 publications

Use of antiretroviral therapy in households and risk of HIV acquisition in rural KwaZulu-Natal, South Africa, 2004–12: a prospective cohort study

Use of antiretroviral therapy in households and risk of HIV acquisition in rural KwaZulu-Natal, South Africa, 2004–12: a prospective cohort study

Baseline Factors Associated with Mortality within Six Months after Admission among Hospitalized HIV-1 Patients in Shenyang, China

Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries

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