Strategies to reduce early morbidity and mortality in adults receiving antiretroviral therapy in resource-limited settings

Abstract

Purpose of review We review recently published literature concerning early morbidity and mortality during antiretroviral therapy (ART) among patients in resource-limited settings. We focus on articles providing insights into this burden of disease and strategies to address it. Recent findings In sub-Saharan Africa mortality rates during the first year of ART are very high (8%-26%), with most deaths occurring in the first few months. This compares to 3%-13% in programmes in Latin America and the Caribbean and 11%-13% in South-East Asia. Risk factors generally reflect late presentation with advanced symptomatic disease. Key causes of morbidity and mortality include tuberculosis, acute sepsis, cryptococcal meningitis, malignancy, wasting syndrome/chronic diarrhoea. Current literature shows the fundamental need is for much earlier HIV diagnosis and initiation of ART. In addition, further studies provide data on the role of screening and prophylaxis against opportunistic diseases (particularly TB, bacterial sepsis and cryptococcal disease) and the management of specific opportunistic diseases and complications of ART. Effective and sustainable delivery of these interventions requires strengthening of programmes. Summary Strategies to address this disease burden should include earlier HIV diagnosis and ART initiation, screening and prophylaxis for opportunistic infections, optimised management of specific diseases and treatment complications, and programme strengthening.

Clinical management of tuberculosis and HIV-1 co-infection

“…Similar findings were noted in a communitybased study in Zimbabwe: duration of infectiousness prior to TB diagnosis was 18 weeks for HIV-1 infected versus 1 yr for HIV-1 uninfected patients [49]. TB may also present as an acute community acquired pneumonia and needs to be considered in any HIV-1 infected patient presenting with acute respiratory illness (table 1) [50,51].…”

The social and clinical characteristics of patients on antiretroviral therapy who are ‘lost to follow-up’ in KwaZulu-Natal, South Africa: a prospective study

“…This finding suggests that treating depression at ART initiation as previously recommended (Jia et al, 2005) may be indicated in this South African population. The results draw attention to the need for early HIV diagnosis, increased access to ART services with earlier treatment initiation, routine screening and aggressive management of opportunistic infections, particularly tuberculosis (Lawn, Harries & Wood, 2010;Macpherson et al, 2008). Differences in health status (lower CD4 cell counts and higher depression scores) should be taken into account when initiating patients on ART.…”

Antiretroviral therapy, CD4, viral load, and disease stage in HIV patients in Saudi Arabia: a 2001–2013 cross-sectional study

“…We anticipated this study would serve as a baseline to measure future progress, a first step to fill in many gaps in the information about medical care of people living of HIV/AIDS in the KSA. Thus, we hope, through further future similar work in the area of HIV medical care, to inform providers to standardize care, reduce morbidity and mortality, monitor and reduce resistance to ART, and ultimately improve the quality of life for those living with HIV/AIDS [11][12][13].…”