Early Mortality in Adults Initiating Antiretroviral Therapy (ART) in Low- and Middle-Income Countries (LMIC): A Systematic Review and Meta-Analysis

Abstract

BackgroundWe systematically reviewed observational studies of early mortality post-antiretroviral therapy (ART) initiation in low- and middle-income countries (LMIC) in Asia, Africa, and Central and South America, as defined by the World Bank, to summarize what is known.Methods and FindingsStudies published in English between January 1996 and December 2010 were searched in Medline and EMBASE. Three independent reviewers examined studies of mortality within one year post-ART. An article was included if the study was conducted in a LMIC, participants were initiating ART in a non-clinical trial setting and were ≥15 years. Fifty studies were included; 38 (76%) from sub-Saharan Africa (SSA), 5 (10%) from Asia, 2 (4%) from the Americas, and 5 (10%) were multi-regional. Median follow-up time and pre-ART CD4 cell count ranged from 3–55 months and 11–192 cells/mm3, respectively. Loss-to-follow-up, reported in 40 (80%) studies, ranged from 0.3%–27%. Overall, SSA had the highest pooled 12-month mortality probability of 0.17 (95% CI 0.11–0.24) versus 0.11 (95% CI 0.10–0.13) for Asia, and 0.07 (95% CI 0.007–0.20) for the Americas. Of 14 (28%) studies reporting cause-specific mortality, tuberculosis (TB) (5%–44%), wasting (5%–53%), advanced HIV (20%–37%), and chronic diarrhea (10%–25%) were most common. Independent factors associated with early mortality in 30 (60%) studies included: low baseline CD4 cell count, male sex, advanced World Health Organization clinical stage, low body mass index, anemia, age greater than 40 years, and pre-ART quantitative HIV RNA.ConclusionsSignificant heterogeneity in outcomes and in methods of reporting outcomes exist among published studies evaluating mortality in the first year after ART initiation in LMIC. Early mortality rates are highest in SSA, and opportunistic illnesses such as TB and wasting syndrome are the most common reported causes of death. Strategies addressing modifiable risk factors associated with early death are urgently needed.

Loss to Follow-Up among a Group of Patients with HIV and Severe Mental Illness in South Africa

“…Although introduction of these medications into high-burden, resource-poor settings was slow to commence and has been inadequate to meet global needs [3] [4], significant portions of populations around the world now have access to antiretroviral therapy (ART) [5]. Key to achieving good outcomes from ART is the ability to remain in medical care on a chronic, long-term basis [6] [7].…”

Rollout of Xpert<SUP>®</SUP> MTB/RIF in Northwest Cambodia for the diagnosis of tuberculosis among PLHA

“…However, underutilization of Xpert, long turnaround times, and use of Xpert as a follow-on diagnostic may undermine the benefit of timely results with Xpert, particularly among PLHA who are at increased risk of death with a delayed TB diagnosis. 28 Strong health systems are imperative to realize the potential of Xpert, including robust specimen referral and result-reporting systems, selection of appropriate testing strategies, and careful placement of machines where they are both accessible and cost-effective.…”

Methadone maintenance treatment and mortality in HIV-positive people who inject opioids in China

“…38,39 Anaemia is known to be an independent predictor of death and disease progression in patients with HIV/AIDS. [39][40][41] Because of the way China's healthcare system is structured, the national ART programme provides treatment for HIV infection through a variety of channels, such as hospitals specializing in infectious diseases, general hospitals and local Center for Disease Control and Prevention facilities.…”