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After long-term ART, HIV mortality in S. Africa, N. America comparable
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Researchers from the University of Cape Town in South Africa have found that the mortality rate among patients on HIV treatment in South African cohorts is comparable to that in North American cohorts after 2 years of ART.
“With increasing duration on ART, mortality in HIV-infected patients on treatment in South Africa declines rapidly to levels approaching those in high-income settings,” the researchers wrote in PLOS Medicine. “Contextual factors related to measurement, health services and patient characteristics account for a large proportion of regional mortality variation and are key to interpreting mortality on ART both within and between settings.”
The researchers evaluated data from four South African cohorts on patients who were lost to follow-up but could be linked to the national population register. These data were combined with data on patients from cohorts in Europe and North America to determine the cumulative mortality, the mortality rate ratios and the predicted mortality rates by region. The rates were observed at 0 to 3 months, 3 to 6 months, 6 to 12 months, 12 to 24 months and 24 to 48 months on ART from 2001 to 2010.
The study included 30,467 adults from South Africa, 29,727 adults from Europe and 7,160 from North America. Patients in South Africa typically began treatment with more advanced disease, with a median CD4 count of 102 cells/mcL compared with a median CD4 count of 213 cells/mcL for patients in Europe and 172 cells/mcL for patients in North America.
The 1-year mortality in South Africa was 9.7% (95% CI, 9.2-10.2) vs. 2% in Europe (95% CI, 1.8-2.2) and 4.6% in North America (95% CI, 4-5.1). The high rate of early mortality in South Africa was most evident among patients who began treatment with a CD4 count <50 cells/mcL.
The mortality rates were lower among patients in Europe and North America vs. South Africa during the first year of ART. In the 12- to 24-month period, the mortality rate was lower in Europe and comparable in North America compared with South Africa. During the 24- to 48-month treatment period, however, the adjusted mortality rate was lower in Europe (RR=0.46; 95% CI, 0.37-0.58) and higher in North America (RR=1.62; 95% CI, 1.27-2.05) compared with South Africa.
“Most European and North American cohorts assume that patients lost to follow-up have the same outcomes as retained patients,” the researchers wrote. “Future cohort analyses of mortality should be explicit as to the frequency and completeness of death registry linkage, the manner in which additional data from registries are incorporated into the data or analyses, and the analytic approach to defining and correcting for losses to care.”
Disclosure: Some researchers report final relationships with Abbott, AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Janssen, Merck, the UK Medical Research Council and ViiV.
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