Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study


Autoři: Rachel A. Silverman aff001;  Grace C. John-Stewart aff001;  Ingrid A. Beck aff006;  Ross Milne aff006;  Catherine Kiptinness aff002;  Christine J. McGrath aff002;  Barbra A. Richardson aff002;  Bhavna Chohan aff002;  Samah R. Sakr aff009;  Lisa M. Frenkel aff002;  Michael H. Chung aff001
Působiště autorů: Department of Epidemiology, University of Washington, Seattle, Washington, United states of America aff001;  Department of Global Health, University of Washington, Seattle, Washington, United states of America aff002;  Department of Population Health Sciences, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, United States of America aff003;  Department of Medicine, University of Washington, Seattle, Washington, United States of America aff004;  Pediatrics, University of Washington, Seattle, Washington, United States of America aff005;  Seattle Children’s Research Institute, Seattle, Washington, United States of America aff006;  Department of Biostatistics, University of Washington, Seattle, Washington, United States of America aff007;  Kenya Medical Research Institute (KEMRI), Nairobi, Kenya aff008;  Coptic Hospital, Nairobi, Kenya aff009;  Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America aff010
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223411

Souhrn

Introduction

Despite increased treatment availability, HIV-infected individuals continue to start antiretroviral therapy (ART) late in disease progression, increasing early mortality risk.

Materials and methods

Nested prospective cohort study within a randomized clinical trial of adult patients initiating ART at clinics in urban Nairobi and rural Maseno, Kenya, between 2013–2014. We estimated mortality incidence rates following ART initiation and used Cox proportional hazards regression to identify predictors of mortality within 12 months of ART initiation. Analyses were stratified by clinic site to examine differences in mortality correlates and risk by location.

Results

Among 811 participants initiated on ART, the mortality incidence rate within a year of initiating ART was 7.44 per 100 person-years (95% CI 5.71, 9.69). Among 207 Maseno and 612 Nairobi participants initiated on ART, the mortality incidence rates (per 100 person-years) were 12.78 (95% CI 8.49, 19.23) and 5.72 (95% CI 4.05, 8.09). Maseno had a 2.20-fold greater risk of mortality than Nairobi (95% CI 1.29, 3.76; P = 0.004). This association remained [adjusted hazard ratio (HR) = 2.09 (95% CI 1.17, 3.74); P = 0.013] when adjusting for age, gender, education, pre-treatment drug resistance (PDR), and CD4 count, but not when adjusting for BMI. In unadjusted analyses, other predictors (P<0.05) of mortality included male gender (HR = 1.74), age (HR = 1.04 for 1-year increase), fewer years of education (HR = 0.92 for 1-year increase), unemployment (HR = 1.89), low body mass index (BMI<18.5 m/kg2; HR = 4.99), CD4 count <100 (HR = 11.67) and 100–199 (HR = 3.40) vs. 200–350 cells/μL, and pre-treatment drug resistance (PDR; HR = 2.49). The increased mortality risk associated with older age, males, and greater education remained when adjusted for location, age, education and PDR, but not when adjusted for BMI and CD4 count. PDR remained associated with increased mortality risk when adjusted for location, age, gender, education, and BMI, but not when adjusted for CD4 count. CD4 and BMI associations with increased mortality risk persisted in multivariable analyses. Despite similar baseline CD4 counts across locations, mortality risk associated with low CD4 count, low BMI, and PDR was greater in Maseno than Nairobi in stratified analyses.

Conclusions

High short-term post-ART mortality was observed, partially due to low CD4 count and BMI at presentation, especially in the rural setting. Male gender, older age, and markers of lower socioeconomic status were also associated with greater mortality risk. Engaging patients earlier in HIV infection remains critical. PDR may influence short-term mortality and further studies to optimize management will be important in settings with increasing PDR.

Klíčová slova:

Antimicrobial resistance – Antiretroviral therapy – Body mass index – Death rates – HIV infections – Kenya – Randomized controlled trials – Socioeconomic aspects of health


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