Early mortality in adults initiating antiretroviral therapy (ART) in low- and middle-income countries (LMIC): a systematic review and meta-analysis

• Published in: PloS one Vol. 6; no. 12; p. e28691
• Main Authors: Gupta, Amita, Nadkarni, Girish, Yang, Wei-Teng, Chandrasekhar, Aditya, Gupte, Nikhil, Bisson, Gregory P, Hosseinipour, Mina, Gummadi, Naveen
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 29.12.2011; Public Library of Science (PLoS)
• Subjects: Acquired immune deficiency syndrome; Adult; Adults; AIDS; Anemia; Antiretroviral agents; Antiretroviral drugs; Antiretroviral therapy; Antiretroviral Therapy, Highly Active - statistics & numerical data; Biology; Body mass; Body mass index; Body size; Cause of Death; CD4 antigen; Developing countries; Developing Countries - economics; Developing Countries - statistics & numerical data; Diarrhea; Drug therapy; HIV; HIV Infections - economics; HIV Infections - mortality; Human immunodeficiency virus; Humans; Illnesses; Income; LDCs; Low income groups; Male; Medicine; Meta-analysis; Mortality; Multivariate analysis; Odds Ratio; Poverty - economics; Poverty - statistics & numerical data; Proportional Hazards Models; Public health; Reviews; Ribonucleic acid; Risk analysis; Risk Factors; RNA; Sexually transmitted diseases; STD; Studies; Survival Analysis; Therapy; Tuberculosis; Asia; United States > US; Maryland; Baltimore Maryland
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0028691

We systematically reviewed observational studies of early mortality post-antiretroviral therapy (ART) initiation in low- and middle-income countries (LMIC) in Asia, Africa, and Central and South America, as defined by the World Bank, to summarize what is known. Studies published in English between January 1996 and December 2010 were searched in Medline and EMBASE. Three independent reviewers examined studies of mortality within one year post-ART. An article was included if the study was conducted in a LMIC, participants were initiating ART in a non-clinical trial setting and were ≥15 years. Fifty studies were included; 38 (76%) from sub-Saharan Africa (SSA), 5 (10%) from Asia, 2 (4%) from the Americas, and 5 (10%) were multi-regional. Median follow-up time and pre-ART CD4 cell count ranged from 3-55 months and 11-192 cells/mm(3), respectively. Loss-to-follow-up, reported in 40 (80%) studies, ranged from 0.3%-27%. Overall, SSA had the highest pooled 12-month mortality probability of 0.17 (95% CI 0.11-0.24) versus 0.11 (95% CI 0.10-0.13) for Asia, and 0.07 (95% CI 0.007-0.20) for the Americas. Of 14 (28%) studies reporting cause-specific mortality, tuberculosis (TB) (5%-44%), wasting (5%-53%), advanced HIV (20%-37%), and chronic diarrhea (10%-25%) were most common. Independent factors associated with early mortality in 30 (60%) studies included: low baseline CD4 cell count, male sex, advanced World Health Organization clinical stage, low body mass index, anemia, age greater than 40 years, and pre-ART quantitative HIV RNA. Significant heterogeneity in outcomes and in methods of reporting outcomes exist among published studies evaluating mortality in the first year after ART initiation in LMIC. Early mortality rates are highest in SSA, and opportunistic illnesses such as TB and wasting syndrome are the most common reported causes of death. Strategies addressing modifiable risk factors associated with early death are urgently needed.