Ten-year survival with analysis of gender difference, risk factors, and causes of death during 13 years of public antiretroviral therapy in rural Kenya: Republication

Abstract

Evidence for why antiretroviral therapy (ART) outcomes differ by gender in developing countries has been inconclusive. In this first study to assess 10-year survival on ART in Kenya, our objective was to compare gender differences in survival for those who began ART as adults and as children. Kakamega County Referral Hospital (KCRH) is a tertiary rural hospital that has provided public ART to Kenyans since 2004. All patients enrolled in ART at KCRH who died between July 2004 and March 2017 and a sample of living patients were included in a survival analysis that bootstrapped sampled data. Case–cohort regressions identified adjusted hazard ratios. In total, 1360 patients were included in the study. Ten-year survival was 77% (95% confidence band [CB] 73–81%), significantly different for men (65%; 95% CB: 45–74%) and women (83%; 95% CB: 78–86%) who began therapy as adults. Ten-year survival was intermediate with no significant gender difference (76%; 95% CB: 69–81%) for patients who began therapy as children. Hazard of death was increased for men (hazard ratio [HR] 1.56; 95% confidence interval [CI] 1.13–2.17), infants (HR 2.87; 95% CI 1.44–5.74), patients with consistently poor clinic attendance (HR 3.94; 95% CI 3.19-4.86), and divorced patients (HR 2.25; 95% CI 1.19–4.25). Tuberculosis, diarrheal illnesses, human immunodeficiency virus (HIV) wasting syndrome, and malaria were leading causes of death. Survival was significantly lower for men than for women in all time periods, but only for patients who began therapy as adults, indicating against biological etiologies for the gender mortality difference.

Gender difference in mortality among pulmonary tuberculosis HIV co-infected adults aged 15-49 years in Kenya

“…When all outcome data were used, the Kaplan-Meier survival curves were still significant in the older age groups of 30 to 39 and 40 to 49 years. Similar age-specific gender difference was reported in a HIV patient cohort from Kenya [ 21 ].…”

“…The significant difference in the older age groups suggest the possible role of poor health seeking behaviour and adherence to treatment among men reported from HIV studies [ 21 ]. Applying the univariable and multivariable models in a sub-analysis for the age group 15 to 24 years, indicate no gender difference, supporting the Kaplan-Meier findings and our proposition of behavioural contribution to the observed difference in the older age groups.…”

Sex stratification of the trends and risk of mortality among individuals living with HIV under different transmission categories

“…Notably, differences in mortality between different transmission categories may be confounded or modified by sex. Studies conducted in Europe 20 , China 15 , 21 , Kenya 22 , and South Africa 23 have reported that female PLWH have a lower risk of mortality than male PLWH. This is possibly because of women’s better adherence to ART 15 , 21 , lower rate of substance use 24 , or more favorable immune response to combined ART (cART) 25 .…”