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Mills E.J.,University of Ottawa | Bakanda C.,The AIDS Support Organization TASO | Birungi J.,The AIDS Support Organization TASO | Chan K.,British Columbia Center for Excellence in | And 4 more authors.
Annals of Internal Medicine | Year: 2011

Background: Little is known about the effect of combination antiretroviral therapy (cART) on life expectancy in sub-Saharan Africa. Objective: To estimate life expectancy of patients once they initiate cART in Uganda. Design: Prospective cohort study. Setting: Public sector HIV and AIDS disease-management program in Uganda. Patients: 22 315 eligible patients initiated cART during the study period, of whom 1943 were considered to have died. Measurements: All-cause mortality rates were calculated and abridged life tables were constructed and stratified by sex and baseline CD4 cell count status to estimate life expectancies for patients receiving cART. The average number of years remaining to be lived by patients who received cART at varying age categories was estimated. Results: After adjustment for loss to follow-up, crude mortality rates (deaths per 1000 person-years) ranged from 26.9 (95% CI, 25.4 to 28.5) in women to 43.9 (CI, 40.7 to 47.0) in men. For patients with a baseline CD4 cell count less than 0.050 × 109 cells/L, the mortality rate was 67.3 (CI, 62.1 to 72.9) deaths per 1000 person-years, whereas among persons with a baseline CD4 cell count of 0.250 × 109 cells/L or more, the mortality rate was 19.1 (CI, 16.0 to 22.7) deaths per 1000 person-years. Life expectancy at age 20 years for the overall cohort was 26.7 (CI, 25.0 to 28.4) additional years and at age 35 years was 27.9 (CI, 26.7 to 29.1) additional years. Life expectancy increased substantially with increasing baseline CD4 cell count. Similar trends are observed for older age groups. Limitations: A small (6.4%) proportion of patients were lost to follow-up, and it was imputed that 30% of these patients had died. Few patients with a CD4 cell count greater than 0.250 × 109 cells/L initiated cART. Conclusion: Ugandan patients receiving cART can expect an almost normal life expectancy, although there is considerable variability among subgroups of patients. © 2011 American College of Physicians.


Bray S.,University of Ottawa | Gedeon J.,University of Ottawa | Hadi A.,University of Ottawa | Kotb A.,University of Ottawa | And 10 more authors.
HIV/AIDS - Research and Palliative Care | Year: 2012

Objective: Although international guidelines recommend initiating antiretroviral therapy (ART) when a patient's CD4 cell count is #350 cells/μL, most patients in resource-limited settings present with much lower CD4 cell counts. The lowest level that their CD4 cell count reaches, the nadir, may have long-term consequences in terms of mortality. We examined this health state in a large cohort of HIV+ patients in Uganda. Design: This was an observational study of HIV patients in Uganda aged 14 years or older, who were enrolled in 10 major clinics across Uganda. Methods: We assessed the CD4 nadir of patients, using their CD4 cell count at initiation of ART, stratified into categories (,50, 50-99, 100-149, 150-249, 250+ cells/μL). We constructed Kaplan-Meier curves to assess the differences in survivorship for patients left-censored at 1 year and 2 years after treatment initiation. We used Cox proportional hazards regression to model the associations between CD4 nadir and mortality. We adjusted mortality for loss-to-follow-up. Results: Of 22,315 patients, 20,129 patients had greater than 1 year of treatment follow-up. Among these patients, 327 (1.6%) died and 444 (2.2%) were lost to follow-up. After left- censoring at one year, relative to lowest CD4 strata, patients with higher CD4 counts had signifcantly lower rates of mortality (CD4 150-249, hazard ratio [HR] 0.60, 95% confidence interval [CI]: 0.45-0.82, P = 0.001; 250+, HR 0.66, 95% CI, 0.44-1.00, P = -0.05). Male sex, older age, and duration of time on ART were independently associated with mortality. When left-censoring at 2 years, CD4 nadir was no longer statistically signifcantly associated with mortality. Conclusion: After surviving for 1 year on ART, a CD4 nadir was strongly predictive of longer- term mortality among patients in Uganda. This should argue for efforts to increase engagement with patients to ensure a higher CD4 nadir at initiation of treatment. © 2012 Bray et al, publisher and licensee Dove Medical Press Ltd.


Bakanda C.,The AIDS Support Organization TASO | Birungi J.,The AIDS Support Organization TASO | Mwesigwa R.,The AIDS Support Organization TASO | Nachega J.B.,University of Cape Town | And 5 more authors.
PLoS ONE | Year: 2011

Background: Adolescents have been identified as a high-risk group for poor adherence to and defaulting from combination antiretroviral therapy (cART) care. However, data on outcomes for adolescents on cART in resource-limited settings remain scarce. Methods: We developed an observational study of patients who started cART at The AIDS Service Organization (TASO) in Uganda between 2004 and 2009. Age was stratified into three groups: children (≤10 years), adolescents (11-19 years), and adults (≥20 years). Kaplan-Meier survival curves were generated to describe time to mortality and loss to follow-up, and Cox regression used to model associations between age and mortality and loss to follow-up. To address loss to follow up, we applied a weighted analysis that assumes 50% of lost patients had died. Findings: A total of 23,367 patients were included in this analysis, including 810 (3.5%) children, 575 (2.5%) adolescents, and 21 982 (94.0%) adults. A lower percentage of children (5.4%) died during their cART treatment compared to adolescents (8.5%) and adults (10%). After adjusting for confounding, other features predicted mortality than age alone. Mortality was higher among males (p<0.001), patients with a low initial CD4 cell count (p<0.001), patients with advanced WHO clinical disease stage (p<0.001), and shorter duration of time receiving cART (p<0.001). The crude mortality rate was lower for children (22.8 per 1000 person-years; 95% CI: 16.1, 29.5), than adolescents (36.5 per 1000 person-years; 95% CI: 26.3, 46.8) and adults (37.5 per 1000 person-years; 95% CI: 35.9, 39.1). Interpretation: This study is the largest assessment of adolescents receiving cART in Africa. Adolescents did not have cART mortality outcomes different from adults or children. © 2011 Bakanda et al.


Okoboi S.,The AIDS Support Organization TASO | Ding E.,The Center for Excellence in AIDS | Persuad S.,University of British Columbia | Wangisi J.,The AIDS Support Organization TASO | And 10 more authors.
AIDS Research and Therapy | Year: 2015

Background: Community-drug distribution point is a care model for stable patients in the community designed to make ART delivery more efficient for the health system and provide appropriate support to encourage long-term retention of patients. We examined program retention among ART program participants in rural Uganda, which has used a community-based distribution model of ART delivery since 2004. Methods: We analyzed data of all patients >18years who initiated ART in Jinja, Ugandan site of The AIDS Support Organization between January 1, 2004 and July 31, 2009. Participants attended clinic or outreach visits every 2-3months and had CD4 cell counts measured every 6months. Retention to care was defined as any patient with at least one visit in the 6months before June 1, 2013. We then identified participants with at least one visit in the 6months before June 1, 2013 and examined associations with mortality and lost-to-follow-up (LTFU). Participants with >4years of follow up during August, 2012 to May, 2013 had viral load conducted, since no routine viral load testing was available. Results: A total of 3345 participants began ART during 2004-2009. The median time on ART in June 2013 was 5.69years. A total of 1335 (40%) were residents of Jinja district and 2005 (60%) resided in outlying districts. Of these, 2322 (69%) were retained in care, 577 (17%) died, 161 (5%) transferred out and 285 (9%) were LTFU. Factors associated with mortality or LTFU included male gender, [Adjusted Hazard Ratio (AHR)=1.56; 95% CI 1.28-1.9], CD4 cell count <50 cells/μL (AHR=4.09; 95% CI 3.13-5.36) or 50-199 cells/μL (AHR=1.86; 95% CI 1.46-2.37); ART initiation and WHO stages 3 (AHR=1.35; 95% CI 1.1-1.66) or 4 (AHR=1.74; 95% CI 1.23-2.45). Residence outside of Jinja district was not associated with mortality/LTFU (p value=0.562). Of 870 participants who had VL tests, 756 (87%) had VLs <50 copies/mL. Conclusion: Community-based ART distribution systems can effectively mitigate the barriers to program retention and result in good rates of virologic suppression. © 2015 Okoboi et al.

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