ArticlesMortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries
Introduction
The increasingly widespread use of highly active antiretroviral therapy (HAART) since 1996 has substantially improved the prognosis of HIV-infected patients who have access to these drugs.1, 2, 3, 4 In resource-poor settings in Africa, Asia, and South America, where 90% of people with HIV/AIDS live, access to HAART is limited. With falling prices of proprietary drugs, the increasing availability of generic formulations and the launch of initiatives by international agencies, including the World Health Organization's (WHO's) “3 by 5” programme (to get 3 million HIV patients on antiretrovirals by 2005), the Global Fund to fight AIDS, Tuberculosis and Malaria, and the US President's Emergency Plan for AIDS Relief (PEPFAR), this situation is changing. The WHO estimates that as of June, 2005, about 1 million people were receiving HAART, although this number still only represents 15% of the estimated 6·5 million people in urgent need of antiretroviral therapy in low-income and middle-income countries.5
Several factors could limit the effectiveness of HAART in resource-poor settings. Interruptions in supply at the programme level or patients' limited financial resources might compromise adherence and treatment efficacy. The high prevalence of co-infections, notably with tuberculosis and other bacterial diseases might also affect prognosis.6, 7, 8 Here we report on the Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration, a network of treatment programmes in Africa, Asia, and South America.9 Our objective was to compare early mortality and immunological and virological response in patients starting HAART in these settings with outcomes in patients participating in a similar collaboration of cohort studies in high-income countries, the ART Cohort Collaboration (ART-CC).1
Section snippets
Participants
Treatment programmes in low-income countries were identified by searching published scientific reports, including abstracts from recent conferences, and by consulting with colleagues. Site assessments were done with a standardised questionnaire. Programmes that collected prospective data on patient characteristics and outcomes were eligible for inclusion in ART-LINC. 23 treatment programmes were approached, 19 agreed to participate, and 18 of these contributed data to this analysis.
Information
Results
The ART-LINC dataset has 6498 treatment-naïve patients with a known date of starting HAART and at least one follow-up; 4810 (74%) patients also had a CD4 count at baseline, and were thus included in the analysis. Compared with treatment-naive patients starting HAART without an immunological assessment, those with a documented baseline CD4 count were less likely to be male and more likely to be treated in publicly funded centres or programmes offering free care.9 The characteristics of the
Discussion
Mortality rates of HIV-infected patients from low-income settings in Africa, South America, and Asia fell substantially within the first few months of HAART, and approached those seen in Western Europe and North America after 4–6 months. Patients in low-income settings started treatment with considerably more advanced immunodeficiency than those from industrialised countries, but virological and immunological response to HAART were similar in both settings, a finding that tallies with results
References (45)
- et al.
Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies
Lancet
(2002) - et al.
Changing patterns of mortality across Europe in patients infected with HIV-1
Lancet
(1998) - et al.
Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohoort study
Lancet
(2005) - et al.
Tuberculosis in HIV-infected patients: a comprehensive review
Clin Microbiol Infect
(2004) - et al.
Assessment of a pilot antiretroviral drug therapy programme in Uganda: patients' response, survival, and drug resistance
Lancet
(2002) - et al.
Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals
Lancet Infect Dis
(2005) - et al.
Equity and health sector reforms: can low-income countries escape the medical poverty trap?
Lancet
(2001) - et al.
Explaining trends in inequities: evidence from Brazilian child health studies
Lancet
(2000) - et al.
Improved survival among HIV-infected patients after initiation of triple-drug antiretroviral regimens
CMAJ
(1999)
Review of human immunodeficiency virus type 1-related opportunistic infections in sub-Saharan Africa
Clin Infect Dis
HIV-1-related morbidity in adults, Abidjan, Cote d'Ivoire: a nidus for bacterial diseases
J Acquir Immune Defic Syndr
Antiretroviral Therapy in Lower Income Countries (ART-LINC): International collaboration of treatment cohorts
Int J Epidemiol
Development and validation of a prognostic model for survival time data: application to prognosis of HIV positive patients treated with antiretroviral therapy
Stat Med
Multiple imputation of missing blood pressure covariates in survival analysis
Stat Med
Multiple imputation for nonresponse in surveys
The role of frailty models and accelerated failure time models in describing heterogeneity due to omitted covariates
Stat Med
Parametric frailty and shared frailty survival models
Stata J
Clinical outcome of patients with HIV-1 infection according to immunologic and virologic response after 6 months of highly active antiretroviral therapy
Ann Intern Med
Limited patient adherence to highly active antiretroviral therapy for HIV-1 infection in an observational cohort study
Arch Intern Med
Insights into the reasons for discontinuation of the first highly active antiretroviral therapy (HAART) regimen in a cohort of antiretroviral naive patients. I.CO.N.A. Study Group. Italian Cohort of Antiretroviral-Naive Patients
AIDS
Impact of new antiretroviral combination therapies in HIV infected patients in Switzerland: prospective multicentre study
BMJ
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