Early Mortality in Adults Initiating Antiretroviral Therapy (ART) in Low- and Middle-Income Countries (LMIC): A Systematic Review and Meta-Analysis
Open Access
- 29 December 2011
- journal article
- research article
- Published by Public Library of Science (PLoS) in PLOS ONE
- Vol. 6 (12), e28691
- https://doi.org/10.1371/journal.pone.0028691
Abstract
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/mm3, 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.Keywords
This publication has 68 references indexed in Scilit:
- Mortality During the First Year of Potent Antiretroviral Therapy in HIV-1-Infected Patients in 7 Sites Throughout Latin America and the CaribbeanJAIDS Journal of Acquired Immune Deficiency Syndromes, 2009
- Effect of Early versus Deferred Antiretroviral Therapy for HIV on SurvivalNew England Journal of Medicine, 2009
- Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studiesThe Lancet, 2009
- Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical modelThe Lancet, 2009
- Five-year outcomes of initial patients treated in Botswana's National Antiretroviral Treatment ProgramAIDS, 2008
- Baseline renal insufficiency and risk of death among HIV-infected adults on antiretroviral therapy in Lusaka, ZambiaAIDS, 2008
- Predictors of mortality in HIV-infected patients starting antiretroviral therapy in a rural hospital in TanzaniaBMC Infectious Diseases, 2008
- Rapid Scale-up of Antiretroviral Therapy at Primary Care Sites in ZambiaJAMA, 2006
- Quantifying heterogeneity in a meta‐analysisStatistics in Medicine, 2002
- Meta-analysis in clinical trialsControlled Clinical Trials, 1986