Mortality and its predictors among antiretroviral therapy naïve HIV-infected individuals with CD4 cell count ≥350 cells/mm ³ compared to the general population: data from a population-based prospective HIV cohort in Uganda

Abstract

BackgroundEvidence exists that even at high CD4 counts, mortality among HIV-infected antiretroviral therapy (ART) naïve individuals is higher than that in the general population. However, many developing countries still initiate ART at CD4 ≤350 cells/mm3.ObjectiveTo compare mortality among HIV-infected ART naïve individuals with CD4 counts ≥350 cells/mm3 with mortality in the general Ugandan population and to investigate risk factors for death.DesignPopulation-based prospective HIV cohort.MethodsThe study population consisted of HIV-infected people in rural southwest Uganda. Patients were reviewed at the study clinic every 3 months. CD4 cell count was measured every 6 months. Rate ratios were estimated using Poisson regression. Indirect methods were used to calculate standardised mortality ratios (SMRs).ResultsA total of 374 participants with CD4 ≥350 cells/mm3 were followed for 1,328 person-years (PY) over which 27 deaths occurred. Mortality rates (MRs) (per 1,000 PY) were 20.34 (95% CI: 13.95–29.66) among all participants and 16.43 (10.48–25.75) among participants aged 15–49 years. Mortality was higher in periods during which participants had CD4 350–499 cells/mm3 than during periods of CD4 ≥500 cells/mm3 although the difference was not statistically significant [adjusted rate ratio (aRR)=1.52; 95% CI: 0.71–3.25]. Compared to the general Ugandan population aged 15–49 years, MRs were 123% higher among participants with CD4 ≥500 cells/mm3 (SMR: 223%, 95% CI: 127–393%) and 146% higher among participants with CD4 350–499 cells/mm3 (246%, 117%–516). After adjusting for current age, mortality was associated with increasing WHO clinical stage (aRR comparing stage 3 or 4 and stage 1: 10.18, 95% CI: 3.82–27.15) and decreasing body mass index (BMI) (aRR comparing categories ≤17.4 Kg/m2 and ≥18.5 Kg/m2: 6.11, 2.30–16.20).ConclusionHIV-infected ART naïve individuals with CD4 count ≥350 cells/mm3 had a higher mortality than the general population. After adjusting for age, the main predictors of mortality were WHO clinical stage and BMI.

Factors associated with mortality in HIV-infected people in rural and urban South Africa

“…Underweight BMI was associated with mortality in both rural and urban areas with a slightly higher hazard in the urban group. Our findings concur with others from previous studies ( 5 , 21 , 29 ). While overweight or obese BMI was not associated with mortality in rural participants, it was associated with decreased mortality in the urban participants.…”

“…Driven by the need to achieve the millennium development goal of increasing the number of HIV-infected people accessing treatment ( 2 ), over 2 million people have been started on ART with another half million planned to be started each year. Mortality in HIV-infected individuals is high ( 3 , 4 ), especially prior to ART treatment and while awaiting ART ( 5 ). This is associated with highly immunosuppressed patients with low CD4 counts and high viral loads.…”

Nutritional status and metabolic risk in HIV-infected university students: challenges in their monitoring and management

“…Nutrition-related complications such as weight loss in this population continue to remain challenging because, even in the context of ART, HIV disease progression seems to be strongly related to a compromised nutritional status. 5 As a low/abnormal body mass index (BMI), especially at the time of ART initiation, has been associated with a higher mortality, 4,6,7 it is extremely important to assess and monitor the nutritional status of newly diagnosed HIV-infected individuals. Apart from the nutritional status of HIV-infected students affecting their health, the quality of life and learning outcomes may also deteriorate in the presence of a compromised nutritional status.…”

Measuring HIV-related mortality in the first decade of anti-retroviral therapy in sub-Saharan Africa

“…Masiira et al used standardized mortality rates (SMR) for HIV-positive, ART-naive Ugandan adults, and compared the mortality of those with CD4 counts between 350 and 499 cells per mm 3 , to those with CD4 counts greater than 500 cells per mm 3 , and with the Ugandan general population (15). Mortality rates were 1.6 times higher in those with lower CD4 counts (between 350 and 499 cells per mm 3 ), and 2.5 times higher than the general population.…”