Mortality and morbidity from HIV has dramatically decreased in both high- and low-income countries. However, some patients may not benefit from combination antiretroviral therapy (cART) because of inadequate access to HIV care, including attrition after care initiation. Moreover, prior work has concentrated on internal comparisons of mortality among HIV-infected patients over time.
This study had two specific aims. For the first aim, we described cumulative incidence rates of attrition and identified independent factors predictive of attrition. For the second aim, we evaluated observed mortality rates, excess mortality rates and standardized mortality ratios across calendar years. Factors associated with excess mortality across calendar time were evaluated in Poisson regression models.
For the first aim, we observed a cumulative probability of attrition from cART initiation of 9% at 12 months, 16% at 24 months and 24% at 60 months. Factors were associated with attrition, including younger age, male gender, and being single or divorced. Patients with higher CD4 cell counts were more likely to drop out. The proportion of patients remaining in HIV care increased in more recent calendar years and among patients who initiated modern cART regimens.
For the second aim, we found observed and excess mortality rates in 2003/2004 of 9.5 deaths/100 person-years and 9.1; and in 2008/2009 these decreased to 5.6 and 5.2 respectively. The adjusted excess hazard ratio (eHR) for 2003/2004 in comparison to 2008/2009 was 1.27 (95% confidence interval [95% CI]: 1.11, 1.45). Patients initiating cART at CD4 cell counts <50 cells/μL in comparison to ≥350 cells/μL had an adjusted eHR of 9.92 (95% CI: 8.59, 11.44). Standardized mortality ratio results were consistent with those for excess mortality.
In summary, attrition can lead to premature morbidity and mortality, and possibly affect further transmission of HIV and HIV resistant drug variants. In China effective strategies may include focusing particularly on younger male patients and those with higher CD4 cell counts at therapy initiation. Moreover, notable substantial decreases in excess mortality were observed from 2003 to 2009 in China among HIV-infected patients receiving free cART. However, mortality among HIV-infected patients remained higher than the general Chinese population.
|Commitee:||Cohen, Myron S., Cole, Stephen R., Eron, Joseph J., Jr., Wohl, David A.|
|School:||The University of North Carolina at Chapel Hill|
|School Location:||United States -- North Carolina|
|Source:||DAI-B 73/06, Dissertation Abstracts International|
|Subjects:||Asian Studies, Public health, Epidemiology|
|Keywords:||Antiretroviral treatment, HIV, HIV resistant drug variants, Mortality rates, Premature morbidity|
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