Predictors of Survival among Adult Ethiopian Patients in the National ART Program at Seven University Teaching Hospitals: A Prospective Cohort Study

Highly active antiretroviral therapy is necessary but not sufficient. A systematic review and meta-analysis of mortality incidence rates and predictors among HIV-infected adults receiving treatment in Ethiopia, a surrogate study for resource-poor settings

BACKGROUND

Owing to the introduction of highly active antiretroviral therapy (HAART), the trajectory of mortality and morbidity associated with human immunodeficiency virus (HIV) infection has significantly decreased in developed countries. However, this remains a formidable public health challenge for people living with HIV in resource-poor settings. This study was undertaken to determine the pooled person-time incidence rate of mortality, analyze the trend, and identify predictors of survival among HIV-infected adults receiving HAART.

METHODS

Quantitative studies were searched in PubMed, Embase, Scopus, Google Scholar, African Journals Online, and Web of Science. The Joana Briggs Institute critical appraisal tool was used to assess the quality of the included articles. The data were analyzed using the random-effects Dersimonian-Laird model.

RESULTS

Data abstracted from 35 articles involving 39,988 subjects were analyzed. The pooled person-time incidence rate of mortality (all-cause) was 4.25 ([95% uncertainty interval (UI), 3.65 to 4.85]) per 100 person-years of observations. Predictors of mortality were patients aged ≥ 45 years (hazard ratio (HR), 1.70 [95% UI,1.10 to 2.63]), being female (HR, 0.82 [95% UI, 0.70 to 0.96]), history of substance use (HR, 3.10 [95% UI, 1.31 to 7.32]), HIV positive status non disclosure (HR, 3.10 [95% UI,1.31 to 7.32]), cluster of differentiation 4 + T cell - count < 200 cells/mm3 (HR, 3.23 [95% UI, [2.29 to 4.75]), anemia (HR, 2.63 [95% UI, 1.32 to 5.22]), World Health Organisation classified HIV clinical stages III and IV (HR, 3.02 [95% UI, 2.29 to 3.99]), undernutrition (HR, 2.24 [95% UI, 1.61 to 3.12]), opportunistic infections (HR, 1.89 [95% UI, 1.23 to 2.91]), tuberculosis coinfection (HR, 3.34 [95% UI, 2.33 to 4.81]),bedridden or ambulatory (HR,3.30 [95% UI, 2.29 to 4.75]), poor treatment adherence (HR, 3.37 [95% UI,1.83 to 6.22]), and antiretroviral drug toxicity (HR, 2.60 [95% UI, 1.82 to 3.71]).

CONCLUSION

Despite the early introduction of HAART in Ethiopia, since 2003, the mortality rate has remained high. Therefore, guideline-directed intervention of identified risk factors should be in place to improve overall prognosis and increase quality-adjusted life years.

Weight loss and mortality in people living with HIV: a systematic review and meta-analysis

BACKGROUND

In the first reported cases of human immunodeficiency virus (HIV) infection, people living with HIV (PLHIV) suffered weight loss, which was an independent predictor of mortality. Highly active antiretroviral therapy (HAART) has changed this scenario for ideal weight, overweight, and even obesity. However, some PLHIV, even on HAART, continue to lose weight. Thus, the guiding question of the study was: do PLHIV hospitalized using HAART with weight loss have higher mortality than hospitalized PLHIV using HAART without weight loss?

METHOD

A systematic review and meta-analysis of prospective cohort studies published in English, Spanish, or Portuguese, searched in the MedLine, Embase, and LILACS databases from March 2020, until October 2023, reported by MOOSE. We analyzed the methodological quality and risk of bias using the Joanna Briggs Institute Critical Appraisal Tool for Cohort Studies; used the risk ratio (RR) to calculate the probability of hospitalized PLWH who lost weight dying, applied the random effect model and created the funnel plot. We used the inverse variance test estimated by the Mantel-Haenszel method, considering a 95% confidence interval (CI), heterogeneity (I2), total effect size (Z), and significance value of p < 0.05. We performed a sensitivity analysis with meta-regression and meta-analyses on subgroups to diagnose influence and outliers. The quality of evidence and strength of recommendation were analyzed using the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE).

RESULTS

We included 10 of the 711 studies identified, totaling 1,637 PLHIV. The studies were from South Africa (1), Canada (1), China (1), Brazil (1), Cameroon (1), Ethiopia (1), Thailand (1), Colombia (1), and Tanzania (2), from 1996 to 2017. The average age of the participants was 33.1 years old, and the male was predominant. The leading causes of hospital admission were related to co-infections, and the average hospitalization time was 20.5 days. The prevalence of death in hospitalized PLHIV using HAART who lost weight was 57.5%, with a 1.5 higher risk of dying (RR: 1.50, 95% CI: 1.03, 2.19, p = 0.04) than hospitalized PLHIV who did not lose weight.

CONCLUSION

We concluded, with a very low confidence level, that that weight loss significantly increased the risk of death in hospitalized PLWH using HAART.

TRIAL REGISTRATION AND FUNDING

PROSPERO International Prospective Register of Systematic Reviews CRD42020191246 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020191246 .

Trends in HIV-1 pretreatment drug resistance and HIV-1 variant dynamics among antiretroviral therapy-naive Ethiopians from 2003 to 2018: a pooled sequence analysis

BACKGROUND

Ethiopia is among the highly HIV-affected countries, with reported 12,000 and 12,000 AIDS-related deaths and incidents as per reports from 2021. Although the country has made a promising progress in antiretroviral therapy, recent studies have indicated that pretreatment drug resistance (PDR) is alarmingly increasing, which has become a challenge for the effectiveness of HIV treatment. Epidemiologic data on PDR is necessary to help establish ART regimens with good efficacy. Thus, this systematic review aimed to determine the trend analysis of PDR among ART-naïve individuals along with HIV variant dynamics in Ethiopia.

METHOD

HIV-1 pol sequences from studies conducted between 2003 and 2018 among ART-naïve Ethiopian individuals were retrieved from GenBank and analyzed for the presence of PDR mutations (PDRM) along with the analysis of HIV-1 variant dynamics. The Calibrated Population Resistance (CPR) tool Version 8.1 and the REGA HIV-1 Subtyping Tool Version 3 were used to determine the PDRM and HIV-1 genetic diversity, respectively.

RESULT

We identified nine studies and analyzed 1070 retrieved HIV-1 pol sequences in this systematic review. The pooled prevalence of PDR was 4.8% (51/1070), including 1.4% (15/1070), 2.8% (30/1070), and 0.8% (9/1070) for nucleoside reverse transcriptase inhibitor (NRTI), non-NRTI (NNRTI), and protease inhibitor (PI) resistance, respectively. NRTI and NNRTI concurrent PDRM were observed among 0.2% (2/799) of the analyzed sequences. The overall PDR prevalence has been increasing over the years. Though the prevalence of the NNRTI, NRTI, and PI PDR also increased over the years, the NNRTI increment was more pronounced than the others, reaching 7.84% in 2018 from 2.19% in 2003. The majority (97%; 1038/1070) of the genetic diversity was HIV-1 subtype C virus, followed by subtype C' (2%; 20/1038) and other subtypes (1%; 10/1038).

CONCLUSIONS

According to this systematic review, the overall pooled prevalence of PDR is low. Despite the low prevalence, there has been an increasing trend of PDR over the years, which implies the need for routine surveillance of PDRMs along with preventive measures. Hence, this supports the recently endorsed transition of ART regimens from NNRTI to integrase strand transfer inhibitor-based regimens recommended by the WHO. In addition, this finding underscores the need for routine baseline genotypic drug resistance testing for all newly diagnosed HIV-infected patients before initiating treatment to halt the upward trend of PDR.

Incidence and predictors of antiretroviral treatment failure among children in public health facilities of Kolfe Keranyo Sub-City, Addis Ababa, Ethiopia: Institution-based retrospective cohort study

BACKGROUND

Human immunodeficiency virus (HIV) infection is a public health concern globally. The number of people living with HIV worldwide in 2018 was estimated at 37.9 million; of those, 1.7 million are children. Globally, 62% of the 37.9 million people were receiving Antiretroviral treatment (ART); and among those who were on ART, 53% had achieved viral suppression. This study aimed to assess the incidence and predictors of Antiretroviral treatment failure among children in Kolfe Keranyo sub-city, Addis Ababa, Ethiopia.

METHODS

An institution-based retrospective cohort study was conducted among 250 children who were enrolled in first-line Antiretroviral treatment from January 2013 to May 2020 in Kolfe Keranyo sub-city. Data was collected by using a data extraction checklist and data were extracted by reviewing children's medical charts and electronic database. Kaplan-Meier method was used to estimate the probability of treatment failure. During bivariable analysis variables with p-value < 0.25 were taken for multivariable Cox regression analysis to assess predictors of treatment failure. Statistically significant association was declared at p-value < 0.05 with a 95% confidence interval.

RESULT

The overall proportion of treatment failure within the follow-up period was 17.2%. This study also found that the overall incidence rate was 3.45 (95% CI: 2.57-4.67) per 1000 person-month observation. Infant prophylaxis for PMTCT (AHR: 3.59, 95% CI: 1.65-7,82), drug substitution (AHR: 0.18, 95% CI: 0.09-0.37), AZT/3TC/NVP based regimen (AHR: 2.27, 95% CI: 1.14-4.25), and more than 3 episodes of poor ART adherence (AHR: 2.27, 95% CI: 1.17-4.38) were found to be predictors of treatment failure among children.

CONCLUSION

High proportion of treatment failure was found among children on first-line ART in Kolfe Keranyo sub-city, Addis Ababa according to the UNAIDs virological suppression targets. Infant prophylaxis for PMTCT, drug substitution, AZT/3TC/NVP based initial regimen, and poor ART adherence were found to be predictors of first-line ART treatment failure. Close follow-up of children on medication adherence and revising the AZT/3TC/NVP based regimen need to be considered.

Survival analysis and predictors of mortality among adult HIV/AIDS patients initiated antiretroviral therapy from 2010 to 2015 in Dubti General Hospital, Afar, Ethiopia: A retrospective cohort study

Background

Although antiretroviral therapy (ART) is well accepted to increase survival of patients with HIV/AIDS, AIDS related deaths continue to be a major problem in sub-Saharan Africa like Ethiopia. Studies have showed variable findings in the survival status of patients with HIV/AIDS initiating ART, and there was no such study in the study area. Therefore, purpose of this study was to determine the survival and predictors of mortality among HIV/AIDS patients starting taking ART in Dubti General Hospital, Afar, Ethiopia.

Methods

A 5 year retrospective cohort study was performed among 702 HIV/AIDS patients aged ≥15 years that started ART between December 31, 2010, and December 31, 2015 in Dubti General Hospital, Afar, Ethiopia. A simple random sampling technique was used to select the study subjects from each WHO stage based stratum. Socio-demographic, clinical and survival status data were extracted by reviewing patients' records. Data were analyzed by using SPSS Version 21. Kaplan-Meier and Cox-regression models were used to estimate survival, and explore predictors of mortality. Variables with a p value of <0.05 in multivariate Cox regression analysis were considered statistically significant.

Results

Among 702 study participants, 82 (11.7%) died during follow up, and the overall incidence rate of mortality was 5.81 per 100 person-years. Identified predictors of mortality were being not married (AHR = 3.71, 95% CI: 1.97-6.99), had no formal education (AHR = 2.33, 95% CI: 1.33-4.38), bedridden functional status (AHR = 5.91, 95% CI: 2.71-12.88), advanced WHO stage III and IV (AHR = 4.36, 95% CI: 2.20-8.64), BMI 16-18.4 kg/m² (AHR = 3.03, 95% CI: 1.50-6.13), and BMI<16.0 kg/m² (AHR = 5.47; 95% CI: 2.85-10.50), CD4 count ≤50 cells/mm³ (AHR = 6.62, 95% CI: 4.73-8.52), hemoglobin <8 g/dl (AHR = 5.21; 95% CI: 2.64-10.26), not used cotrimoxazole prophylaxis therapy (AHR = 2.78, 95% CI: 1.61-4.73), stavudine based regimen (AHR = 2.34, 95% CI: 1.32-4.13), and zidovudine based regimen (AHR = 2.49, 95% CI: 1.41-4.39).

Conclusion

High mortality was observed in this cohort, and participants with stage III and IV, low CD4 count, low hemoglobin level, bed ridden functional status, low BMI should be closely monitored even with the scarce resources. In addition, the use of cotrimoxazole prophylaxis therapy should be more encouraged to increase survival.

Effect of active tuberculosis on the survival of HIV-infected adult patients who initiated antiretroviral therapy at public hospitals of Eastern Ethiopia: A retrospective cohort study

BACKGROUND

In resource-limited countries such as Ethiopia, tuberculosis is the major cause of morbidity and mortality among people living with the human immunodeficiency virus. In the era of antiretroviral therapy, the effect of tuberculosis on the survival of patients who are living with human immunodeficiency virus has been poorly understood in Ethiopia. Therefore, this study aimed to determine the effect of active tuberculosis on the survival of HIV-infected adult patients who initiated antiretroviral therapy in public hospitals in Eastern Ethiopia.

METHODS

An institution-based retrospective cohort study was conducted among 566 participants from January 1, 2014, to June 30, 2018. The collected data were entered into EpiData version 3.1 before being exported to Stata version 14 for analysis. A Cox proportional hazard model was used to determine the effect of active tuberculosis on the survival of HIV-infected adult patients who initiated antiretroviral therapy, and a p-value less than 0.05 and a 95% confidence level were used to declare statistical significance.

RESULT

Of the 566 patients included in the study, 76 died. The mortality rate was 11.04 per 100 person-years in tuberculosis co-infected patients, while it was 2.52 per 100 person-years in non-tuberculosis co-infected patients. The patients with tuberculosis co-infection had a 2.19 times higher hazard of death (AHR: 2.19; 95% CI: 1.17, 4.12) compared to those without tuberculosis. Advanced clinical stage, low CD4+ cell count, and previous episodes of an opportunistic infection other than tuberculosis were found to be independent predictors of mortality.

CONCLUSION

Co-infection with tuberculosis at antiretroviral therapy initiation increases the hazard of death approximately two-fold. Hence, we recommend key organizations to enhance the region's collaborative interventional and preventative strategies for TB and HIV.

Predictors of Survival Time Among HIV-Infected Adults After Initiating Anti-Retroviral Therapy in Kombolcha Town: A 5-Year Retrospective Cohort Study

Background

Antiretroviral therapy (ART) enhances the survival of HIV-infected patients by reducing viral load and increasing CD4. As CD4 count increases, patients are more protected against opportunistic infections. In developing countries including Ethiopia, there were limited studies about the survival benefit of ART particularly no study in Kombolcha Town. Thus, this study was aimed to address the gap.

Methods

A hospital-based retrospective cohort study was employed in Kombolcha town among 510 patients’ records from January 2015 to December 2019. A systematic random sampling technique was used to select patient records. The collected data were checked, coded, and entered into Epidata version 4.6 and exported to Statistical Package for Social Sciences version 26 for data cleaning and analysis. Kaplan–Meier was used to estimate the probability of category of each predictor and a log rank test was used to compare survival curves. Bivariate and multivariate Cox-regression were employed using a 95% CI and variables with p-value <0.05 were declared as predictors of poor survival time.

Results

In this cohort, out of 510 HIV-infected patients, 39 (7.65%) were died, and 471 (92.35%) were censored. Fair drug adherence (AHR=6.88, 95% CI: 4.31–24.04), Poor drug adherence (AHR=9.58, 95% CI: 8.72–30.97), CD4 count <50 cell/µL (AHR=9.38, 95% CI: 1.48–59.31), CD4 count 50–99 cell/µL (AHR=9.67, 95% CI: 1.80–51.73), bedridden (AHR=9.5, 95% CI: 4.49–18.66), opportunistic infections (AHR=4.58, 95% CI: 1.20–5.65), weight <60kg (AHR=2.48, 95% CI:1.59, 10.38), WHO stage III (AHR=3.56, 95% CI: 1.71–17.89), WHO stage IV (AHR=4.42, 95% CI:1.75–25.93) were predictors of poor survival time.

Conclusion

The Kaplan–Meier result showed that the estimated median survival time of patients after ART initiation in Kombolcha town was higher (32 months) as compared to other studies. Poor drug adherence, WHO stage III & IV, Lower baseline CD4 count, presence of opportunistic infections, weight <60kg, and being bedridden were predictors of poor survival time. Thus, early initiation of ART ought to be encouraged among HIV-infected patients and good patient counseling on the level of adherence should be strengthened.

Time to lost to follow-up and its predictors among adult patients receiving antiretroviral therapy retrospective follow-up study Amhara Northwest Ethiopia

Antiretroviral therapy lowers viral load only when people living with HIV maintain their treatment retention. Lost to follow-up is the persistent major challenge to the success of ART program in low-resource settings including Ethiopia. The purpose of this study is to estimate time to lost to follow-up and its predictors in antiretroviral therapies amongst adult patients. Among registered HIV patients, 542 samples were included. Data cleaning and analysis were done using Stata/SE version 14 software. In multivariable Cox regression, a p-value < 0.05 at 95% confidence interval with corresponding adjusted hazards ratio (AHR) were statistically significant predictors. In this study, the median time to lost to follow-up is 77 months. The incidence density of lost to follow-up was 13.45 (95% CI: 11.78, 15.34) per 100 person-years. Antiretroviral therapy drug adherence [AHR: 3.04 (95% CI: 2.18, 4.24)], last functional status [AHR: 2.74 (95% CI: 2.04, 3.67)], and INH prophylaxis [AHR: 1.65 (95% CI: 1.07, 2.56) were significant predictors for time to lost to follow-up. The median time to lost was 77 months and incidence of lost to follow-up was high. Health care providers should be focused on HIV counseling and proper case management focused on identified risks.

Liberia adherence and loss-to-follow-up in HIV and AIDS care and treatment: A retrospective cohort of adolescents and adults from 2016-2019

Antiretroviral therapy (ART) is a lifesaving intervention for people living with HIV infection, reducing morbidity and mortality; it is likewise essential to reducing transmission. The "Treat all" strategy recommended by the World Health Organization has dramatically increased ART eligibility and improved access. However, retaining patients on ART has been a major challenge for many national programs in low- and middle-income settings, despite actionable local policies and ambitious targets. To estimate retention of patients along the HIV care cascade in Liberia, and identify factors associated with loss-to-follow-up (LTFU), death, and suboptimal treatment adherence, we conducted a nationwide retrospective cohort study utilizing facility and patient-level records. Patients aged ≥15 years, from 28 facilities who were first registered in HIV care from January 2016 -December 2017 were included. We used Cox proportional hazard models to explore associations between demographic and clinical factors and the outcomes of LTFU and death, and a multinomial logistic regression model to investigate factors associated with suboptimal treatment adherence. Among the 4185 records assessed, 27.4% (n = 1145) were males and the median age of the cohort was 37 (IQR: 30-45) years. At 24 months of follow-up, 41.8% (n = 1751) of patients were LTFU, 6.6% (n = 278) died, 0.5% (n = 21) stopped treatment, 3% (n = 127) transferred to another facility and 47.9% (n = 2008) were retained in care and treatment. The incidence of LTFU was 46.0 (95% CI: 40.8-51.6) per 100 person-years. Relative to patients at WHO clinical stage I at first treatment visit, patients at WHO clinical stage III [adjusted hazard ratio (aHR) 1.59, 95%CI: 1.21-2.09; p <0.001] or IV (aHR 2.41, 95%CI: 1.51-3.84; p <0.001) had increased risk of LTFU; whereas at registration, age category 35-44 (aHR 0.65, 95%CI: 0.44-0.98, p = 0.038) and 45 years and older (aHR 0.60, 95%CI: 0.39-0.93, p = 0.021) had a decreased risk. For death, patients assessed with WHO clinical stage II (aHR 2.35, 95%CI: 1.53-3.61, p<0.001), III (aHR 2.55, 95%CI: 1.75-3.71, p<0.001), and IV (aHR 4.21, 95%CI: 2.57-6.89, p<0.001) had an increased risk, while non-pregnant females (aHR 0.68, 95%CI: 0.51-0.92, p = 0.011) and pregnant females (aHR 0.42, 95%CI: 0.20-0.90, p = 0.026) had a decreased risk when compared to males. Suboptimal adherence was strongly associated with the experience of drug side effects-average adherence [adjusted odds ratio (aOR) 1.45, 95% CI: 1.06-1.99, p = 0.02) and poor adherence (aOR 1.75, 95%CI: 1.11-2.76, p = 0.016), and attending rural facility decreased the odds of average adherence (aOR 0.01, 95%CI: 0.01-0.03, p<0.001) and poor adherence (aOR 0.001, 95%CI: 0.0004-0.003, p<0.001). Loss-to-follow-up and poor adherence remain major challenges to achieving viral suppression targets in Liberia. Over two-fifths of patients engaged with the national HIV program are being lost to follow-up within 2 years of beginning care and treatment. WHO clinical stage III and IV were associated with LTFU while WHO clinical stage II, III and IV were associated with death. Suboptimal adherence was further associated with experience of drug side effects. Active support and close monitoring of patients who have signs of clinical progression and/or drug side effects could improve patient outcomes.

Predictors of attrition among adults in a rural HIV clinic in southern Mozambique: 18-year retrospective study

HIV remains a major cause of morbidity and mortality for people living in many low-income countries. With an HIV prevalence of 12.4% among people aged over 15 years, Mozambique was ranked in 2019 as one of eight countries with the highest HIV rates in the world. We analyzed routinely collected data from electronical medical records in HIV-infected patients aged 15 years or older and enrolled at Carmelo Hospital of Chokwe in Chokwe from 2002 to 2019. Attrition was defined as individuals who were either reported dead or lost to follow-up (LTFU) (≥ 90 days since the last clinic visit with missed medical pick-up after 3 days of failed calls). Kaplan–Meier survival curves and Cox regression analyses were used to model the incidence and predictors of time to attrition. From January 2002 to December 2019, 16,321 patients were enrolled on antiretroviral therapy (ART): 59.2% were women, and 37.9% were aged 25–34 years old. At the time of the analysis, 7279 (44.6%) were active and on ART. Overall, the 16,321 adults on ART contributed a total of 72,987 person-years of observation. The overall attrition rate was 9.46 per 100 person-years. Cox regression showed a higher risk of attrition in those following an inpatient regimen (hazard ratio [HR] 3.18, 95% confidence interval [CI] 2.89–3.50; p < 0.001), having CD4 counts under 50 cells/µL (HR 1.91, 95% CI 1.63–2.24, p < 0.001), receiving anti-TB treatment within 90 days of ART initiation (HR 6.53, 95% CI 5.72–7.45; p < 0.001), classified as WHO clinical stage III (HR 3.75, 95% CI 3.21–4.37; p < 0.001), and having Kaposi’s sarcoma (HR 1.99, 95% CI 1.65–2.39, p < 0.001). Kaplan–Meier analysis showed that patients with CD4 counts of less than 50 cells/µL on ART initiation had a 40% lower chance of survival at 18 years. Low CD4 cell counts, ART initiation as an inpatient, WHO clinical stage III, and anti-tuberculosis treatment within 90 days of ART initiation were strongly associated with attrition. Strengthening HIV testing and ART treatment, improving the diagnosis of tuberculosis before ART initiation, and guaranteed psychosocial support systems are the best tools to reduce patient attrition after starting ART.

Predictors of mortality rate among adult HIV-positive patients on antiretroviral therapy in Metema Hospital, Northwest Ethiopia: a retrospective follow-up study

Background

Globally Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is an ongoing public health issue associated with high morbidity and mortality. Efforts have been made to reduce HIV/AIDS-related morbidity and mortality by delivering antiretroviral therapy. However, the incidence and predictors of mortality in border areas like Metema were not investigated. This study aimed to assess predictors of mortality rate among adult HIV-positive patients on antiretroviral therapy at Metema Hospital.

Methods

Retrospective follow-up study was employed among ART patients from January 1, 2013, to December 30, 2018. Data were entered in Epi-data 3.1 and exported to STATA 14 for analysis. Kaplan–Meier and Log-Rank test was used to compare survival differences among categories of different variables. In bi-variable analysis p-values < 0.20 were entered into a multivariable analysis. Multivariate Weibull model was used to measure the risk of death and identify the significant predictors of death. Variables that were statistically significant at p-value < 0.05 were concluded as predictors of mortality.

Result

A total of 542 study participants were included. The overall incidence rate was 6.7 (95% CI: 5.4–8.4) deaths per 100 person-years of observation. Being male (HR = 2.4; 95% CI: 1.24–4.62), STAGE IV (HR = 5.64; 95% CI: 2.53–12.56), stage III (HR = 3.31; 95% CI: 1.35–8.10), TB-coinfection (HR = 3.71; 95% CI: 1.59–8.64), low hemoglobin (HR = 4.14; 95% CI: 2.18–7.86), BMI ≤ 15.4 kg/m² (HR = 2.45; 95% CI: 1.17–5.10) and viral load > 1000 copy/ml (HR = 6.70; 95% CI: 3.4–13.22) were found to be a significant predictor for mortality among HIV patients on ART treatment.

Conclusion

The incidence of death was high. Being male, viral load, those with advanced STAGE (III & IV), TB co-infected, low BMI, and low hemoglobin were at a higher risk of mortality. Special attention should be given to male patients and high public interventions needed among HIV patients on ART to reduce the mortality rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00353-z.

Survival and Predictors of Mortality Among HIV Positive Adult Patients on Highly Active Antiretroviral Therapy in Public Hospitals of Kambata Tambaro Zone, Southern Ethiopia: A Retrospective Cohort Study

Background

Human Immune Deficiency Virus (HIV) infection remains the leading cause of morbidity and mortality. In Ethiopia, despite test and treat all HIV positives are adopted, a significant number of people eligible for Anti-Retroviral Therapy (ART) show up with advanced disease and at lower CD4 count. There is currently paucity of studies conducted that investigate predictors of mortality among adults on ART in the study area.

Objective

To explore Survival and predictors of mortality among adult HIV-positive patients on ART in Kambata Tambaro Zone, Ethiopia, from August 2013 to February 2019.

Methods

A health facility-based retrospective cohort study was conducted among records of 467 adult HIV-positive patients on ART selected using simple random sampling. Data were collected using standardized abstraction tool. Kaplan–Meier, Log rank tests and Cox regression model was applied to estimate survival status and identify predictors of mortality, respectively.

Results

Of the total 467 study subjects, 59 (12.63%) of them died in the study period. The median follow-up time of the cohort was 40.1 (IQR=13.6–59.0) months. The mortality rate of the cohort was 4.1 per 100 PYO. The overall survival probability of the cohort was 84.38% (95 CI=80.08–87.82) at 66 months. Bedridden function AHR=3.0 (95% CI, 1.44–6.64), Fair-adherence AHR=3.3 (95% CI, 1.50–7.07), Poor-adherence AHR=3.8 (95% CI, 1.88–7.96), presence of OIs AHR=4.2 (95% CI, 1.98–8.50), Late diagnosis (CD4 count >/=350) AHR=3.0 (95% CI, 1.91–6.42) and Immunologic failure AHR=3.5 (95% CI, 1.41–6.29) were independent predictors of time to death in Cox-Regression.

Conclusion

Late Diagnosis, poor adherence, being bedridden, having OI and Immunologic failure were independently associated with time to death. Early diagnosis to start treatment and emphasizing on close follow-up care to improve treatment adherence should be given special emphasis.

Environmental contamination and risk factors for geohelminth transmission in three informal settlements in Durban metropole, South Africa

Informal settlements/slums are characterised by a lack of adequate sanitation and safe drinking water. Contaminated soil and water sources combined with poor hygiene and environmental conditions results in the transmission of soil transmitted helminths to humans. The aim of the present study was to assess environmental contamination and risk factors for geohelminth transmission in three informal settlements in Durban, South Africa. Each settlement had different types of sanitation facilities namely; flush toilets, pit latrines and chemical toilets. Thirty adult members from 30 households from each settlement were interviewed to determine their knowledge, attitudes and behaviour on geohelminth transmission. Furthermore, two hundred soil samples were collected from areas considered potential sources of infection and processed for the detection and identification of geohelminth eggs. Prevalence and intensities of geohelminth infections from school-age children were also assessed. From the total collection in the three settlements, 31.6% (95/190) were positive for geohelminth eggs with Ascaris lumbricoides, Trichuris trichiura and Taenia spp. eggs being recovered. Quarry Road West (57%; 114/200) showed the highest levels of soil contamination followed by Briardene (27%; 54/200) and Smithfield (11%; 22/200). Stool samples collected from 135 children were found to contain parasite eggs of A. lumbricoides and T. trichiura. Prevalences and intensities of infection were highest in Quarry Road West for both A. lumbricoides (42%, 57/135; 6.0eggs/g) and T. trichiura (10%, 14/135; 1.9eggs/g) and 9.6% (13/135) harboured dual infections. Open defaecation by community members was observed as the main contributing factor for the presence of geohelminth eggs in soil.

Survival and Predictors of Mortality Among Adult HIV/AIDS Patients Initiating Highly Active Antiretroviral Therapy in Debre-Berhan Referral Hospital, Amhara, Ethiopia: A Retrospective Study

Background

Acquired immune deficiency syndrome is one of the most destructive epidemics the world has ever witnessed. An estimated 36.9 million people were living with HIV in 2017. HIV/AIDS is the major contributing factor for morbidity and mortality in low- and middle-income countries. Although different studies on survival and predictors of mortality among HIV/AIDS patients after initiation of antiretroviral therapy were conducted, there are inconsistencies in the findings of those studies. Furthermore, to the authors’ knowledge, there was a dearth of studies conducted in this study area.

Purpose

The purpose of this study was to assess the survival and predictors of mortality among adult patients starting highly active antiretroviral therapy at Debre Berhan Referral Hospital, North Showa, Amhara, Ethiopia.

Patients and Methods

An institution-based retrospective study was conducted among the medical records of 447 study subjects’ selected using simple random sampling from January 1t, 2013 to December 30, 2018. The data was collected using a structured data abstraction checklist and analyzed using Kaplan–Meier statistics and Cox regression models.

Results

Among 447 adult patients, 54 patients (12.1%) had died, giving a crude death rate of 4.18 per 100 person years (95% CI=3.20–5.45). The overall estimated survival rate after initiation of antiretroviral therapy was 81.7% (95% CI=75.36–86.54%) at 72 months of follow-up. The independent predictors of mortality were clinical stage IV (HR=15.6, 95% CI=6.609–36.948), baseline opportunistic infections (HR=1.86, 95% CI=1.048–3.330), baseline Hgb<10 mg/dL (HR=4.655, 95% CI=2.253–9.619), baseline CD4<200 cells/µL (HR=4.71, 95% CI=2.275–9.751), the presence of comorbidity (HR=2.56 95% CI=1.391–4.740), being widowed (HR=3.475, 95% CI=1.412–8.550), and bedridden functional status (HR=3.069, 95% CI=1.111–8.480).

Conclusion

Patients with opportunistic infections, advanced clinical stage disease, bedridden functional status, baseline Hgb<10 mg/dL, baseline CD4<200 cells/µL, and comorbidity should be given special care.

Effectiveness of same-day antiretroviral therapy initiation in retention outcomes among people living with human immunodeficiency virus in Ethiopia: empirical evidence

BACKGROUND

In August 2016, Ethiopia endorsed a universal "test and treat" strategy for people living with human immunodeficiency virus (PLHIV) based on World Health Organization recommendation. However, there is limited evidence on the routine application of the same-day "test and treat" recommendation in low-income settings. This study assessed the effect of same-day treatment initiation on individual-level retention at 6- and 12-months follow-up.

METHODS

A multicenter facility-based retrospective cohort study was conducted to compare retention-in-care between PLHIV who started antiretroviral therapy (ART) on the same-day and those started ART > 7 days following HIV diagnoses. Participants were at least 15 years-old and were newly diagnosed and started on ART between October 2016 and July 2018 in 11 health facilities in the Amhara region of Ethiopia. Multivariable logistic regression controlling for potential confounders and Kaplan-Meier survival analysis were used to assess differences in outcomes between the groups.

RESULTS

In total, 433 PLHIV started ART on the same-day of diagnosis and 555 PLHIV who started ART > 7 days after HIV diagnosis were included in the study. At 6-months, 82.0% (355) in the same-day group vs 89.4% (496) in the > 7 days group were retained-in-care (absolute risk difference (RD) = 7.4%; 95% confidence interval (CI): 2.9-11.8%). At 12-months, 75.8% (328) in the same-day group vs 82.0% (455) in the > 7 days group were retained-in-care (absolute RD = 6.2%; 95% CI: 1.1, 11.4%). The major drop in retention was in the first 30 days following ART initiation among same-day group. After adjusting for baseline and non-baseline covariates, the same-day group was less likely to be retained-in-care at 6- and 12-months (adjusted risk ratio (RR) = 0.89; 95% CI: 0.87, 0.90 and adjusted RR = 0.86; 95% CI: 0.83, 0.89, respectively).

CONCLUSIONS

Reduced retention-in-care can threaten the benefit of the same-day "test and treat" policy. The policy needs to be implemented cautiously with greater emphasis on assessment and preparation of PLHIV for ART to ensure treatment readiness before starting them on same-day ART and close monitoring of patients during early follow-up periods.

Temporal trends of early mortality and its risk factors in HIV-infected adults initiating antiretroviral therapy in Uganda

BACKGROUND

A decline in mortality rates during the first 12 months of antiretroviral therapy (ART) has been mainly linked to increased ART initiation at higher CD4 counts and at less advanced World Health Organization (WHO) clinical stages of HIV infection; however, the role of improved patient care has not been well studied. We estimated improvements in early mortality due to improved patient care.

METHODS

We conducted a retrospective cohort study of HIV-infected individuals ages 18 and older who initiated ART at the Mengo HIV Counseling and Home Care Clinic between 2006 and 2016. We conducted a mediation analysis using generalized structural equation models with inverse odds ratio weighting to estimate the natural direct and indirect effects of ART initiation time on early mortality.

FINDINGS

Among 6,847 patients, most were female (69%), with a median age of 32 (interquartile range [IQR] = 28-38), versus a median age of 38 (IQR = 32-45) for males. The median CD4 count at ART initiation increased from 142 cells/ul (95% confidence interval [CI] = 135-150) in 2006-2010 to 302 cells/ul (95% CI = 283-323) in 2015-2016 (p < 0·001). The number of patients at WHO clinical stages I/II increased from 52% in 2006-2010 to 78% in 2015-2016 (p < 0·001). Annual early mortality decreased from 8·8 deaths/100 person years (PYS) in 2006 to 2.5 deaths/100 pys in 2016 (p < 0·001). Mediation by CD4 counts and WHO clinical stages accounted for 54% of the total effect of ART initiation timing on early mortality. In comparison, 46% remained as the direct effect, reflecting the contribution of improved patient care.

INTERPRETATION

Improved patient care practices should be promoted as a strategy for reducing early mortality after ART initiation, above and beyond the effects from ART initiation at higher CD4 counts and less advanced WHO clinical stage alone.

FUNDING

This research was supported by the President's Emergency Plan for AIDS Relief (PEPFAR), the National Institute of Allergy and Infectious Diseases Division of Intramural Research, and the National Cancer Institute.

Magnitude of opportunistic diseases and their predictors among adult people living with HIV enrolled in care: national level cross sectional study, Ethiopia

Background

Opportunistic diseases cause morbidity and mortality among human immunodeficiency virus (HIV) infected persons. There is dearth of evidence on the magnitude and predictors of opportunistic diseases among PLHIV in Ethiopia. This study was conducted to determine the magnitude and predictors of opportunistic diseases among adults enrolled in the national HIV/AIDS care and treatment services and generate information for program planning and medicine quantification in the country.

Methods

A health facility-based cross-sectional study was conducted. Probability proportional to size and random sampling methods were employed to select health facilities and medical records of adult HIV-infected patients respectively. A total of 7826 medical records were reviewed from 60 health facilities nationwide. Socio-demographic and clinical data including diagnosis of opportunistic diseases were collected from the medical records. Period prevalence of opportunistic diseases over one year period was determined. Bivariate and multivariate logistic regression was used to measure associations between independent variables and the dependent variable, occurrence of opportunistic diseases.

Results

Of the total of 7826 study participants, 3748 (47.9%) were from hospitals and 4078 were from health centers. The majority (61.8%) were female. The median age was 32 years with interquartile range (IQR) of 27–40. The median duration of stay in HIV care was 56 (IQR = 28–80) months; 7429 (94.9%) were on antiretroviral treatment. A total of 1665 cases of opportunistic diseases were recorded with an overall prevalence estimated at 21.3% (95% confidence interval (CI): 20.36, 22.18%). Skin diseases (4.1%), diarrhea (4.1%), bacterial pneumonia (3.6%), recurrent upper respiratory tract infections (3.1%) and tuberculosis (2.7%) were the leading opportunistic diseases. Isoniazid preventive therapy coverage among eligible patients was 24.8%. Persons with a CD4 count < 200 cells/mm³ [adjusted odds ratio (AOR) 1.80, 95% CI: 1.45, 2.23]; and who were bed ridden or ambulatory functional status [AOR (95% CI) = 3.19 (2.32, 4.39)] were independent predictors of diagnosis of opportunistic diseases.

Conclusion

Opportunistic diseases were found to be pervasive among HIV infected adults in Ethiopia. Proactive identification and management, and prevention of opportunistic diseases should be strengthened especially among females, ambulatory or bed-ridden, and patients with low CD4 cell count.

Performance of the Antiretroviral Treatment Program in Ethiopia, 2005-2015: strengths and weaknesses toward ending AIDS

BACKGROUND

Ethiopia is one of the countries which has scaled up antiretroviral treatment (ART) over the past decade. This study reviews the performance of the ART program in Ethiopia during the past decade, and identifies successes and weaknesses toward ending AIDS in the country.

METHODS

A review and synthesis of data was conducted using multiple data sources: reports from all health facilities in Ethiopia to the Federal Ministry of Health, HIV/AIDS estimates and projections, and retrospective cohort and cross-sectional studies conducted between 2005/6 and 2014/15.

FINDINGS

The ART program has been successful over several critical areas: (1) ART coverage improved from 4% to 54%; (2) the median CD4 count/mm³ at the time of ART initiation increased from 125 in 2005/6 to 231 in 2012/13; (3) retention in care after 12 months on ART has increased from 82% to 92%. In spite of these successes, important challenges also remain: (1) ART coverage is not equitable: among regions (5.6%-93%), between children (25%) and adults (60%), and between female (54%) and male patients (69%); (2) retention in care is variable among regions (83%-94%); and, (3) the shift to second-line ART is slow and low (0·58%).

INTERPRETATION

The findings suggest that the ART program should sustain the successes and reflect on the shortcomings toward the goal of ending AIDS. It is important to capitalize on and calibrate the interventions and approaches utilized to scale up ART in the past. Analysis of the treatment cascade, in order to pinpoint the gaps and identify appropriate solutions, is commendable in this regard.

Establishing a Multicenter Longitudinal Clinical Cohort Study in Ethiopia: Advanced Clinical Monitoring of Antiretroviral Treatment Project

BACKGROUND

The purpose of this paper is to describe the establishment of the Advanced Clinical Monitoring of ART Project in Ethiopia for monitoring and evaluation of the longitudinal effectiveness of the ART program and to show the opportunities it presents. This cohort was established in response to the 2005 call by WHO for establishing additional mechanisms for stronger monitoring of ART and the need for creating the platform to generate evidence to guide the care given for the ever increasing number of patients on ART in Ethiopia.

METHOD

A participatory and multi-stage process which started from a consensus building workshop and steered by a mother protocol as well as guiding documents which dictated the degree of engagement and expectations was followed. The primary and secondary aims of the study were agreed upon. A multi-site longitudinal observational clinical cohort was established by a consortium of stakeholders including seven Ethiopian medical schools and their affiliated referral hospitals, John Hopkins University, Ethiopian Public Health Institute, Ministry of Science and Technology, US Centers for Disease Prevention and Control - CDC-Ethiopia, and the Federal Ministry of Health. Adult and adolescent cohorts covering the age range of 14+ years) and pediatric cohorts covering those below age 14 years were the two main cohorts. During the initial recruitment of these cohorts information was extracted from existing documents for a total of 2,100 adult participants. In parallel, a prospective cohort of 1,400 adult and adolescent patients were enrolled for ART initiation and follow-up. Using similar recruitment procedures, a total of 120 children were enrolled in each of retrospective and prospective cohorts. Replacement of participants were made in subsequent years based on lost follow up and death rates to maintain adequacy of the sample to be followed-up.

ACHIEVEMENTS

Between January 2005 and August 2013 a total of 4,339 patients were followed for a median of 41.6 months and data on demographic characteristics, baseline and ongoing clinical features, hospitalization history, medication and laboratory information were collected. 39,762 aliquots and 25,515 specimens of plasma and dryblood-spots respectively were obtained and stored longitudinally from October 2009 to August 2013. The project created a research platform for researchers, policy and decision makers. Moreover, it encouraged local and international investigators to identify and answer clinically and programmatically relevant research questions using the available data and specimens. Calls for concept notes paired with multiple trainings to stimulate investigators to conduct analyses further boosted the potential for doing research.

CONCLUSIONS

A comprehensive and resourceful mechanism for scientific inquiry was established to support the national HIV/ART program. With meaningful involvement and defined roles, establishment of a study, which involved multiple institutions and investigators, was possible. Since ACM is the largest multi-site clinical cohort of patients on antiretroviral treatment in Ethiopia-which can be used for research and for improving clinical management-considering options to sustain the project is crucial.