Open AccessPredictors of mortality in adult people living with HIV on antiretroviral therapy in Nepal: A retrospective cohort study, 2004-2013
Author(s) -
Mirak Raj Angdembe,
Anjana Rai,
Kiran Bam,
Satish Raj Pandey
Publication year - 2019
Publication title -
plos one
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.99
H-Index - 332
ISSN - 1932-6203
DOI - 10.1371/journal.pone.0215776
Subject(s) - medicine , retrospective cohort study , demography , proportional hazards model , mortality rate , cohort study , cohort , antiretroviral therapy , young adult , human immunodeficiency virus (hiv) , viral load , immunology , sociology
Background In Nepal, since 2004, 19,388 people living with HIV (PLHIV) have been enrolled on antiretroviral therapy (ART). The aim of this study was to measure mortality rate and to identify predictors of mortality in adult (≥15 years) PLHIV who initiated ART between 2004 and 2013 in five large ART centers of Nepal. Methods This retrospective cohort study of 3,799 (60.5% male) adult PLHIV uses secondary data collected from standard ART registers. Time from ART initiation (baseline) to death or censoring (loss to follow-up or December 31, 2013) was assessed. Mortality rates per 100 person-years were calculated. Kaplan-Meier models were used to estimate the probability of mortality over time. Predictors of mortality were determined using Cox-regression models. Results The overall mortality rate was 6.98 (95% CI: 6.46–7.54) per 100 person-years, 4.11 (95% CI: 3.53–4.79) in females and 9.14 (95% CI: 8.36–9.99) in males. Mortality rates were higher in early months after ART initiation, particularly in the first three months. Baseline predictors of mortality were ART center, male gender (adjusted HR = 2.08, 95% CI: 1.69–2.57), residence outside the ART district (AHR = 1.45, 95% CI:1.19–1.76), World Health Organization clinical stage III (AHR = 1.67, 95% CI: 1.13–2.46) and IV (AHR = 2.21, 95% CI: 1.45–3.36), bedridden <50% time in the last month (AHR = 1.92, 95% CI: 1.52–2.41), bedridden >50% time in the last month (AHR = 3.82, 95% CI: 2.95–4.94), lower bodyweight/kg (AHR = 1.04, 95% CI: 1.03–1.05), CD4 count <150 cell/mm 3 (AHR = 2.14, 95% CI: 1.05–4.34) and treatment not switched to second-line regimen (AHR = 3.05, 95% CI: 1.35–6.90). Conclusions Mortality rates were higher soon after ART initiation, particularly in males and gradually decreased over time. Poor baseline clinical characteristics were significantly associated with higher mortality. Increased ART coverage with decentralization of sites to lower levels including community dispensing, differentiated and improved service delivery and initiation of ART at a less advanced disease stage may reduce early mortality.