Date Published: February 11, 2019
Publisher: Public Library of Science
Author(s): Zhigang Zheng, Jinying Lin, ZhenZhen Lu, Jinming Su, Jianjun Li, Guangjie Tan, Chongxing Zhou, Wenkui Geng, Peter Alwin Bock.
To evaluate the mortality risk in the HIV-positive population, we conducted an observational cohort study involving routine data collection of HIV-positive patients who presented at HIV clinics and multiple treatment centers throughout Guangxi province, Southern China in 2011. The patients were screened for tuberculosis (TB) and tested for hepatitis B (HBV) and C (HCV) virus infections yearly. Following the registration, the cohort was followed up for a 60-month period till the end-point (December 31, 2015). Univariable and multivariable Cox proportional hazards regression models were used to analyze the hazard ratio (HR) and 95% confidence interval (95% CI) for mortality after adjusting for confounding factors stratified by patients’ sociodemographic and behavioral characteristics. HRs were compared within risk-factor levels. With the median follow-up of 3.7-person years for each individual, 5,398 (37.8%) (of 14,293 patients with HIV/AIDS) died; among whom, 78.4% were antiretroviral therapy (ART)-naïve; 43.6% presented late; and 12.2% and 3.3% of patients had Mycobacterium tuberculosis (MTB) and HBV and HCV co-infection, respectively. Of individuals with CD4 counts, those with CD4 count >350 cells/μL formed 14.0% of those who died. Furthermore, gender [multivariable HR (95% CI):1.94 (1.68–2.25)], Han ethnicity [2.15 (1.07–4.32)], illiteracy [3.28 (1.96–5.5)], elementary education [2.91 (1.8–4.72)], late presentation [2.89 (2.46–3.39)], and MTB co-infection [1.28 (1.10–1.49)] strongly increased the all-cause mortality risk of HIV-positive individuals. The HR for ART-based stratification was 0.08 (0.07–0.09); and for HBV and HCV co-infection, HR was 1.02 (0.86–1.21). The findings emphasized that accessibility to HIV testing among high-risk populations and screening for viral hepatitis and TB co-infection are important for the survival of HIV-positive individuals. Initiating early ART, even for individuals with higher CD4 counts, is advisable to help increase the prolongation of lives within the community.
With the emergence of the human immunodeficiency virus (HIV) pandemic in the 1980s, a major upsurge in tuberculosis (TB) cases and TB-related mortality has been observed in many countries . TB is the most common opportunistic infectious disease among people living with HIV in developing countries . Mycobacterium tuberculosis (MTB) infection is the leading cause of death among HIV-positive individuals . Among patients with TB and HIV co-infection in some countries, more than 50% have died during the process of anti-TB therapy, the death mainly occurred within two months of TB diagnosis [4–6]. Although ART has been proved to be a crucial intervention to reduce the risk of death among HIV-positive TB patients [4,7], in some resource-limited countries with ART coverage less than 30%, heavy disease burden caused by the higher mortality of HIV-positive patients with TB have resulted [8–12]. In cases involving TB co-infection with HIV, ART can further decrease treatment adherence of anti-TB drugs , thus increasing the risk of death, and persistent transmission among these patients [14,15].
In this observational cohort of over 14,000 individuals, we identified demographic predictors such as gender, Han ethnicity, illiteracy, elementary education, late presentation, and MTB co-infection, which were independent risk factors of all-cause mortality among HIV positive individuals during the 5-year follow-up. The HRs of mortality were higher among males, Han ethnicity, low education, and late presentation, but lower with higher ART coverage. Hepatitis co-infection was not associated with an increase in mortality.
The important strength of our study was the determination of mortality, the risk factors, and the quantitative mortality of risk among different stratifications of behavior, and demographic characteristics. A significantly higher mortality was observed among HIV positive individuals with TB co-infection (HR = 1.28), late presentation (HR = 2.89), while ART was a protective factor against mortality (HR = 0.08). These findings emphasize the importance of improving HIV test accessibility for high risk populations as early as possible, intensifying TB and hepatitis case detection among HIV positive patients sooner, initiating ART even at higher CD4 count, to save more lives in the community.