[pronut-hiv] Mortality and causes of death amongst people taking HIV treatment in Senegal examined

["ProNut-HIV" <pronut-hiv@healthnet.org>]

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Mortality and causes of death amongst people taking HIV treatment in
Senegal examined 

" A body mass index below 19kg/m2 and a haemoglobin level below 10g/dl 
associated with an increased risk of death"

A study conducted in Senegal suggests that individuals who die after
commencing anti-HIV therapy are most likely to do so in the first year
of antiretroviral therapy, largely because antiretroviral therapy was
only initiated when they were already very ill because of HIV. The
study, published in the May edition of AIDS, also found that
mycobacterial infections, particularly tuberculosis (TB), cause a
significant number of deaths, and the investigators also speculate that
some of the TB-associated deaths could have been caused by immune
reconstitution inflammatory syndrome (IRIS). 

Senegal initiated an antiretroviral access programme, providing triple
drug therapy in 1998 and investigators looked at the survival of 404
individuals who entered this programme between 1998 and 2002. Follow-up
data were available until 2005, with the median duration of follow-up
being a little short of four years. 

Almost all the patients (94%) had symptoms of HIV infection or had
progressed to AIDS when they started HIV therapy. Median CD4 cell count
was 128 cells/mm3 and median viral load was over 100,000 copies/ml. Only
5% of patients had taken any form of anti-HIV treatment before. 

Median CD4 cell count increased by 104 cells/mm3 six months after
starting HIV treatment and by 300 cells/mm3 after four years. Median
viral load fell by 3 log10/ml six months after the initiation of
treatment and did not change substantially thereafter. 

A total of 93 individuals died during follow-up, with an overall
mortality rate of 6.6 deaths per 100 person years. However, most of
these deaths, 47 (with an additional seven patients lost to follow-up
and assumed dead), occurred during the first year of anti-HIV therapy,
yielding a mortality rate for that year of 12.5 deaths per 100 person
years for this year. This fell in the second year to 6.6 deaths per 100
person years and kept falling thereafter (4.5, 2.3, 2.2 deaths per 100
person years in years three, four and five respectively). 

The risk of dying during the first year of anti-HIV treatment was
associated with CD4 cell count before potent antiretroviral therapy was
initiated, with, unsurprisingly, patients with a CD4 cell count below 50
cells/mm3 having the highest risk (18%) and those with a CD4 cell count
above 200 cells/mm3 the lowest (6%). 

As well as CD4 cell count, the investigators identified a body mass
index below 19kg/m2 and a haemoglobin level below 10g/dl as being
associated with an increased risk of death. It is well known that both
of these factors are associated with an increased risk of death. 

Attention was then turned to causes of death, which were known for 80 of
the 93 patients. Pulmonary TB explained 17 deaths, eight of which
occurred in the first year of anti-HIV treatment. The investigators also
noted that nine of the patients who died of TB had a history of the
infection dating back to before the initiation of HIV therapy,
suggesting that the recurrence of TB may have been due to IRIS.
Infections of the central nervous system also caused 17 deaths,
septicaemia caused eight deaths, with a similar number caused by
unspecified disease. In addition, five deaths were caused by liver
failure, with hepatitis B infection present in one patient and hepatitis
C in another. Side-effects of antiretroviral therapy are thought to have
contributed to three deaths, including one case of diabetes, one case of
high amylase and a case of lactic acidoisis. 

"Efforts towards an earlier initiation of HAART in the course of HIV
infection and a better approach to diagnosis and management of
tuberculosis and opportunistic infections will be the next step to limit
the still too high mortality," conclude the investigators. 

Reference 

Etard J-F et al. Mortality and causes of death in adults receiving
highly active antiretroviral therapy in Senegal: a 7-year cohort study.
AIDS 20: 1181 - 1189, 2006.