Mortality During the First Year of Potent Antiretroviral Therapy in HIV-1-Infected Patients in 7 Sites Throughout Latin America and the Caribbean

Abstract

Background Although nearly 2 million people live with HIV in Latin America and the Caribbean, mortality rates after initiation of highly active antiretroviral therapy (HAART) have not been well-described. Methods 5,152 HIV-infected, antiretroviral-naïve adults from clinics in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru starting HAART during 1996–2007 were included. First-year mortality rates and their association with demographics, regimen, baseline CD4, and clinical stage were assessed. Results Overall 1-year mortality rate was 8.3% (95% confidence interval [CI]:7.6–9.1%), although variable across sites: 2.6, 3.7, 6.0, 13.0, 10.8, 3.5, and 9.8% for clinics in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru, respectively. 80% of deaths occurred within the first 6 months. Median baseline CD4 was 107 cells/μL, ranging from 79 (Peru) to 163 (Argentina). Mortality estimates adjusting for CD4 were similar across sites (1.1–2.8% for CD4=200), except for Haiti, 7.5%, and Honduras, 7.0%. Death was associated with lower CD4 (adjusted hazard ratio [HR] for CD4=200 vs CD4=50 was 0.58; 95% CI:0.40–0.85) and clinical AIDS (HR=3.1; 95% CI:2.1–4.5). Conclusions Mortality rates were similar to those reported elsewhere for resource-limited settings. Disease stage at HAART initiation, treatment eligibility criteria, program age, and background mortality rates may explain some variability in prognosis between sites.

Effectiveness of Highly Active Antiretroviral Therapy (HAART) Among HIV-Infected Patients in Mexico

“…8,13 Presentation with advanced disease, as defined as CD4 þ counts lower than 200 cells=mm 3 or the occurrence of an AIDS-defining illness, is a well known risk factor for early mortality and virologic failure among individuals initiating HAART. 14,15 The frequency of advanced disease in our population is similar or even higher than cohorts reported from low-income countries, even though Mexico is considered a middle-income country.…”

Cryptococcosis in Acquired Immunodeficiency Syndrome Patients Clinically Confirmed and/or Diagnosed at Necropsy in a Teaching Hospital in Brazil

“…At admission, disseminated fungal infection and advanced immunodeficiency at admission are often seen. 23,24 Unfortunately, the ideal antifungal therapy for this disease is not available in most places due to its high cost, which also contributes to the poor outcome. In contrast, the reports from Europe and the United States have shown an impressive decrease of prevalence and mortality rates related to cryptococcosis and other opportunistic infections after the introduction of ART in 1995.…”

“…4 This figure is similar to that of Latin American countries where most HIV-infected patients are also severely immunocompromised when they start the ART or discover their HIV status and/or are hospitalized. 23,24 Probably, a high and unknown number of AIDS patients die before cryptococcosis diagnosis is performed or antifungal therapy started, and the lack and/or a progressive decrease of necropsy performance in most teaching hospitals hinder a definitive postmortem diagnosis in these cases. The prevalence of this mycosis associated to AIDS in necropsy reports from teaching hospitals around the world during the last years showed rates ranging from 3.8% to 22.8% (Table 3).…”

“…21 According to several authors, a late HIV diagnosis was performed in 45-76% of cases in two great case series of cryptococcosis reported from that region contrasting with the figures of 15-38% from Europe. [22][23][24] Nowadays, the epidemiological scenario in poor-resource settings exhibits an unacceptable and high mortality rate of 63% directly related to cryptococcosis. Most of these patients are unaware of their HIV status or do not receive or present poor compliance to ART.…”

Effect of cotrimoxazole on mortality in HIV-infected adults on antiretroviral therapy: a systematic review and meta-analysis

“…4 Moreover, after adjusting for immunodeficiency at baseline, mortality during the first months of ART was higher in lowincome countries than in high-income countries. 4,5 High mortality rates early in ART have been documented in Africa, 6 the Caribbean, 7 Latin America 7 and south-eastern Asia. 8,9 Consequently, additional interventions are needed to decrease early mortality during ART in low-and middle-income countries.…”