Date Published: April 23, 2019
Publisher: Public Library of Science
Author(s): Mirak Raj Angdembe, Anjana Rai, Kiran Bam, Satish Raj Pandey, Almoustapha Issiaka Maiga.
In Nepal, since 2004, 19,388 people living with HIV (PLHIV) have been enrolled on antiretroviral therapy (ART). The aim of this study was to measure mortality rate and to identify predictors of mortality in adult (≥15 years) PLHIV who initiated ART between 2004 and 2013 in five large ART centers of Nepal.
This retrospective cohort study of 3,799 (60.5% male) adult PLHIV uses secondary data collected from standard ART registers. Time from ART initiation (baseline) to death or censoring (loss to follow-up or December 31, 2013) was assessed. Mortality rates per 100 person-years were calculated. Kaplan-Meier models were used to estimate the probability of mortality over time. Predictors of mortality were determined using Cox-regression models.
The overall mortality rate was 6.98 (95% CI: 6.46–7.54) per 100 person-years, 4.11 (95% CI: 3.53–4.79) in females and 9.14 (95% CI: 8.36–9.99) in males. Mortality rates were higher in early months after ART initiation, particularly in the first three months. Baseline predictors of mortality were ART center, male gender (adjusted HR = 2.08, 95% CI: 1.69–2.57), residence outside the ART district (AHR = 1.45, 95% CI:1.19–1.76), World Health Organization clinical stage III (AHR = 1.67, 95% CI: 1.13–2.46) and IV (AHR = 2.21, 95% CI: 1.45–3.36), bedridden <50% time in the last month (AHR = 1.92, 95% CI: 1.52–2.41), bedridden >50% time in the last month (AHR = 3.82, 95% CI: 2.95–4.94), lower bodyweight/kg (AHR = 1.04, 95% CI: 1.03–1.05), CD4 count <150 cell/mm3 (AHR = 2.14, 95% CI: 1.05–4.34) and treatment not switched to second-line regimen (AHR = 3.05, 95% CI: 1.35–6.90). Mortality rates were higher soon after ART initiation, particularly in males and gradually decreased over time. Poor baseline clinical characteristics were significantly associated with higher mortality. Increased ART coverage with decentralization of sites to lower levels including community dispensing, differentiated and improved service delivery and initiation of ART at a less advanced disease stage may reduce early mortality.
Globally, 17 out of 36.7 million people living with HIV (PLHIV) had access to antiretroviral therapy (ART) in 2015 . With increased service coverage and sustained access to ART, new HIV transmission is being averted, preventing millions of AIDS related deaths worldwide. An estimated 7.8 million AIDS related deaths were averted between 2000 and 2014 due to ART roll out. This includes 5.2 million deaths in low and middle-income countries .
Between January 1, 2004 and December 31, 2013, there were 3,799 PLHIV on ART who were eligible for the study. Of these, 754 (19.8%) were lost to follow up, 2,294 (60.4%) were on treatment, three were stopped treatment and 748 (19.7%) had died. The causes of death were not documented. Thus, the results presented are of all-cause mortality.
Since the start of ART services in 2004, Nepal has continuously expanded the number of ART centers, all of which serve an estimated 14,544 PLHIV (currently on ART as of July 2017) . This retrospective cohort study analyzed 10 years of data of PLHIV on ART from five large ART centers with the aim to help understand mortality and its predictors.
Following ART initiation in adult PLHIV, mortality rate was high, particularly in males and gradually decreased over time. Poor baseline clinical characteristics (i.e. WHO clinical stage, performance scale, bodyweight and CD4 count) were significantly associated with higher mortality. Additionally, those receiving ART from centers in Far-Western part of Nepal, male and residing in district other than the one where ART center is located had higher risk of death. Switching treatment to second line regimen reduced the risk of death. Important predictors of mortality must be addressed to improve outcomes of long term ART. Increase in ART coverage with decentralization of sites to lower levels including community dispensing, differentiated and improved service delivery, and initiation of ART at a less advanced disease stage may reduce early mortality.