Effects of Antiretroviral Therapy on the Survival of Human Immunodeficiency Virus-positive Adult Patients in Andhra Pradesh, India: A Retrospective Cohort Study, 2007-2013

Abstract

ObjectivesThe survival outcomes of antiretroviral treatment (ART) programs have not been systematically evaluated at the state level in India. This retrospective study assessed the survival rates and factors associated with survival among adult human immunodeficiency virus (HIV)-infected patients in Andhra Pradesh, India.MethodsThe present study used data from 139 679 HIV patients aged ≥15 years on ART who were registered from 2007 to 2011 and were followed up through December 2013. The primary end point was death of the patient. Mortality densities (per 1000 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore the factors associated with survival.ResultsThe overall median follow-up time was 16.0 months (2.0 months for the deceased and 14.0 months for those lost to follow-up). Approximately 13.2% of those newly initiated on ART died during follow-up. Of those deaths, 56% occurred in the first three months. The crude mortality rate was 80.9 per 1000 person-years at risk. The CD4 count (adjusted hazard ratio [aHR],4.88; 95% confidence interval [CI], 4.36 to 5.46 for <100 cells/mm3 vs. >350 cells/mm3), functional status (aHR, 3.05; 95% CI, 2.82 to 3.30 for bedridden vs. normal), and body weight (aHR, 3.69; 95% CI, 3.42 to 3.97 for <45 kg vs. >60 kg) were strongly associated with the survival of HIV patients.ConclusionsThe study findings revealed that high mortality was observed within the first three months of ART initiation. Patients with poor baseline clinical characteristics had a higher risk of mortality. Expanded testing and counseling should be encouraged, with the goal of ensuring early enrollment into the program followed by the initiation of ART in HIV-infected patients.

How varying CD4 criteria for treatment initiation was associated with mortality of HIV-patients? A retrospective analysis of electronic health records from Andhra Pradesh, India

“…Further, the overall excess risk of death was 84% (HR = 1.84, 95% CI = 1.66-2.04) for 2007-08 period (CD4 ≤ 200 cells/mm 3 ), and 61% (HR = 1.61, 95% CI = 1.46-1.79) for 2009-11 period (CD4 ≤ 250 cells/mm 3 ) compared to 2012 onwards (CD4 ≤ 350 cells/mm 3 ) criteria. These findings are in agreement with other studies published from resource-limited settings [9,27,28]. An increased level of CD4 count is always linked with a decreased risk of a new AIDS event or death [29][30][31].…”

“…This indicates majority of these patients were accessed ART at the later stage of their disease, and explained by the fact that more than one-third (38.4%) of these patients had both CD4 cell count ≤ 200 cells/mm 3 and WHO clinical stage III/IV at the time of treatment start. Other Indian [9,16,18,19] and international [10,[33][34][35][36] studies conducted in the other low-and middle-income countries confirmed similar findings. Several self-perceived personal (such as service delivery, financial, personal health perception, and logistical) and structural barriers may also play a significant role in delaying ART accessing at the earlier stage [37].…”

“…Females are regularly tested during the antenatal care visits or when their spouse show any symptoms leading to earlier diagnosis and treatment of HIV, which could be a reason for their decreased risk of mortality. Though, a gender-wise separate analysis in the same state indicated an increased risk of death in older females with the advanced clinical stages and lower CD4 counts [9]. This could be a result of social discrimination against females, awareness regarding HIV, and no direct health care facilities.…”

“…The 2013 World Health organisation (WHO) ART guidelines strongly recommended initiating ART for all adults PLHIV with a CD4 count ≤ 500 cells/mm 3 , regardless of WHO clinical stage [7]. Early start of ART is associated with reduced risk of AIDS progression or death, TB, other coinfections and increased likelihood of immune recovery [8][9][10]. Additionally, evidence from a randomized controlled trial indicated that earlier ART can significantly reduce the risk of HIV to HIV-negative sexual partners in heterosexual couples [11].…”

Survival rate and mortality risk factors among TB–HIV co-infected patients at an HIV-specialist hospital in Myanmar: A 12-year retrospective follow-up study

“…Patients with advanced stages or complicated cases were referred to MSH for terminal care, as it is an HIV-specialist hospital. A 7-year retrospective cohort study from India also reported a high mortality rate for such patients (Bajpai et al, 2016).…”