Causes of death in adults receiving ARV therapy in Senegal
Polly Clayden, HIV i-Base
Eric Delaporte from the University of Montpelier presented findings from a ANRS study to evaluate survival and causes of death among HIV positive adults receiving ART in Senegal.
The Senagal programme was initiated in 1998 and was the first government sponsored ARV initiative in Africa. Mortality was assessed in patients enrolled between August 1998 and April 2002 (n=404).
First-line regimen comprised 2 NRTI and either an NNRTI or a PI. Follow-up visits were every 2 months with a complete biological assessment every 6 months. Dr Delaporte explained that, a high mortality rate was observed after treatment. Most likely causes of death were established through medical records for deaths in hospital and through post mortem interviews with relatives for deaths at home or where there were no records.
Patients (54.7% women) were followed for a median of 46 months (IQR 32-57 months) after HAART initiation as of September 30, 2005. At baseline, 94.5% were ART naive, 39% and 55% were at CDC stage B and C, respectively. Median age, CD4 count, and viral load were respectively 37 years (range 31-43 years), 128 cells/mm3 (IQR 54-217 cells/mm3), and 5.2 log copies/mL (IQR: 4.7-5.6 log copies/mL).
At baseline, ARV therapy was free for 40.7% of patients, and became free for all patients after 2003.
During follow-up, 93 patients died and the overall incidence rate of death was 6.2/100 person-years (95% CI: 5.0 to 7.6). During the first year after HAART initiation, 47 patients died and 7 were lost to follow-up, a probability of dying of 11.7% (8.5% to 15.3%).
The death rate, highest during the first year after HAART initiation, decreased with time to a cumulative probability of dying of: 17.4% (13.9 to 21.4%), 21.0% (17.3 to 25.4%), 22.9% (19.1 to 27.5%), 24.6% (20.4 to 29.4%) and 25.7% (21.1 to 31.0%) at the end of the following years.
A Coxs model found a body mass index >/=19 kg·m2, AHR 0.54 (95%C!: 0.35-0.82), an haemoglobin level >/=10 g/dL, AHR 0.56 (0.37-0.85), and a CD4 cells count =200 cells/mm3, AHR 0.43 (0.24-0.77) as predictors of survival.
Causes of death were established in 89 cases. mycobacterial infections (n=17), neurotropic infections (n=16), and septicemia (n=10) were the most frequent likely causes of death.
The investigators concluded that although ART was effective in reducing mortality in the short term, mortality after initiating ART remains high compared to other settings. They found:
- The role of IRIS needs to be investigated.
- Infectious disease related deaths predominate (TB, neurotropic infections)
- Diagnosis and treatment of TB and OIs needs to be improved.
Etard JF, Dieng A, Diouf A et al. Mortality and causes of death in adults receiving HAART in Senegal: A 7-Year cohort study. 13th CROI, Denver, 2006. Abstract 63.