High mortality rates in men initiated on anti-retroviral treatment in KwaZulu-Natal, South Africa

Abstract

In attaining UNAIDS targets of 90-90-90 to achieve epidemic control, understanding who the current utilizers of HIV treatment services are will inform efforts aimed at reaching those not being reached. A retrospective chart review of CAPRISA AIDS Treatment Program (CAT) patients between 2004 and 2013 was undertaken. Of the 4043 HIV-infected patients initiated on ART, 2586 (64.0%) were women. At ART initiation, men, compared to women, had significantly lower median CD4+ cell counts (113 vs 131 cells/mm3, p <0.001), lower median body mass index (BMI) (21.0 vs 24.2 kg/m2, p<0.001), higher mean log viral load (5.0 vs 4.9 copies/ml, p<0.001) and were significantly older (median age: 35 vs. 32 years, p<0.001). Men had higher mortality rates compared to women, 6.7 per 100 person-years (p-y), (95% CI: 5.8–7.8) vs. 4.4 per 100 p-y, (95% CI: 3.8–5.0); mortality rate ratio: 1.54, (95% CI: 1.27–1.87), p <0.001. Age-standardised mortality rate was 7.9 per 100 p-y (95% CI: 4.1–11.7) for men and 5.7 per 100 p-y (95% CI: 2.7 to 8.6) for women (standardised mortality ratio: 1.38 (1.15 to 1.70)). Mean CD4+ cell count increases post-ART initiation were lower in men at all follow-up time points. Men presented later in the course of their HIV disease for ART initiation with more advanced disease and experienced a higher mortality rate compared to women.

Joint modelling of longitudinal and time-to-event data: an illustration using CD4 count and mortality in a cohort of patients initiated on antiretroviral therapy

“…Results from the longitudinal sub-model (random effects multivariable model), showed no statistical difference between the urban and rural sites in terms of the CD4 count improvement over time, with patients from the urban site having a higher rate of change. This finding reaffirms the results obtained by [7,26,27]. Men and older people on average initiated ART with significantly lower CD4 counts.…”

“…The subjects have large CD4 count evolutions over time, this suggests that perhaps linear mixed models with random intercepts and slopes could be plausible starting points. There were 161 (11,1%) and 235 (9.2%) men and women lost to follow-up respectively, with men having higher lost to follow-up rates in our cohort in keeping with reports from published literature [23][24][25]. Moreover, patients who were lost to follow-up had a mean of 33.0 years of age and had on average, a CD4 count of 135.8 cells/μL compared to a mean CD4 count of 140.7 cells/μL for patients who were not lost to follow-up.…”

“…In our setting, it has been shown that patients who started ART with low CD4 count have an increased risk of death [7] and it is in keeping with research from other settings [8]. Even though longitudinal CD4 count was not used in these findings, one can deduce that these patients' CD4 count recovery over time would have been slow and hence they died.…”

“…In our setting it has been shown that gender is associated with both CD4 count and mortality [7]. Therefore, descriptive data, which was stratified by gender were presented as medians with interquartile range, percentages and graphical exploration was used where applicable.…”

Improvements in the South African HIV care cascade: findings on 90‐90‐90 targets from successive population‐representative surveys in North West Province

“…Other discrepancies and the wide range of estimates of the first 90 might be due to large regional differences in testing uptake; although national and regional data in this case are similar. Nonetheless, our findings contribute to growing evidence that diagnosis remains a major barrier to achieving 90‐90‐90 and to the increasing consensus that given the large disparity in knowledge of status among men, who test less frequently and who have poorer HIV outcomes over the lifecourse as compared to women ; new programming must creatively target men .…”