Cargando…

Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study

INTRODUCTION: Despite increased treatment availability, HIV-infected individuals continue to start antiretroviral therapy (ART) late in disease progression, increasing early mortality risk. MATERIALS AND METHODS: Nested prospective cohort study within a randomized clinical trial of adult patients in...

Descripción completa

Detalles Bibliográficos
Autores principales: Silverman, Rachel A., John-Stewart, Grace C., Beck, Ingrid A., Milne, Ross, Kiptinness, Catherine, McGrath, Christine J., Richardson, Barbra A., Chohan, Bhavna, Sakr, Samah R., Frenkel, Lisa M., Chung, Michael H.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777822/
https://www.ncbi.nlm.nih.gov/pubmed/31584992
http://dx.doi.org/10.1371/journal.pone.0223411
_version_ 1783456672652460032
author Silverman, Rachel A.
John-Stewart, Grace C.
Beck, Ingrid A.
Milne, Ross
Kiptinness, Catherine
McGrath, Christine J.
Richardson, Barbra A.
Chohan, Bhavna
Sakr, Samah R.
Frenkel, Lisa M.
Chung, Michael H.
author_facet Silverman, Rachel A.
John-Stewart, Grace C.
Beck, Ingrid A.
Milne, Ross
Kiptinness, Catherine
McGrath, Christine J.
Richardson, Barbra A.
Chohan, Bhavna
Sakr, Samah R.
Frenkel, Lisa M.
Chung, Michael H.
author_sort Silverman, Rachel A.
collection PubMed
description INTRODUCTION: Despite increased treatment availability, HIV-infected individuals continue to start antiretroviral therapy (ART) late in disease progression, increasing early mortality risk. MATERIALS AND METHODS: Nested prospective cohort study within a randomized clinical trial of adult patients initiating ART at clinics in urban Nairobi and rural Maseno, Kenya, between 2013–2014. We estimated mortality incidence rates following ART initiation and used Cox proportional hazards regression to identify predictors of mortality within 12 months of ART initiation. Analyses were stratified by clinic site to examine differences in mortality correlates and risk by location. RESULTS: Among 811 participants initiated on ART, the mortality incidence rate within a year of initiating ART was 7.44 per 100 person-years (95% CI 5.71, 9.69). Among 207 Maseno and 612 Nairobi participants initiated on ART, the mortality incidence rates (per 100 person-years) were 12.78 (95% CI 8.49, 19.23) and 5.72 (95% CI 4.05, 8.09). Maseno had a 2.20-fold greater risk of mortality than Nairobi (95% CI 1.29, 3.76; P = 0.004). This association remained [adjusted hazard ratio (HR) = 2.09 (95% CI 1.17, 3.74); P = 0.013] when adjusting for age, gender, education, pre-treatment drug resistance (PDR), and CD4 count, but not when adjusting for BMI. In unadjusted analyses, other predictors (P<0.05) of mortality included male gender (HR = 1.74), age (HR = 1.04 for 1-year increase), fewer years of education (HR = 0.92 for 1-year increase), unemployment (HR = 1.89), low body mass index (BMI<18.5 m/kg(2); HR = 4.99), CD4 count <100 (HR = 11.67) and 100–199 (HR = 3.40) vs. 200–350 cells/μL, and pre-treatment drug resistance (PDR; HR = 2.49). The increased mortality risk associated with older age, males, and greater education remained when adjusted for location, age, education and PDR, but not when adjusted for BMI and CD4 count. PDR remained associated with increased mortality risk when adjusted for location, age, gender, education, and BMI, but not when adjusted for CD4 count. CD4 and BMI associations with increased mortality risk persisted in multivariable analyses. Despite similar baseline CD4 counts across locations, mortality risk associated with low CD4 count, low BMI, and PDR was greater in Maseno than Nairobi in stratified analyses. CONCLUSIONS: High short-term post-ART mortality was observed, partially due to low CD4 count and BMI at presentation, especially in the rural setting. Male gender, older age, and markers of lower socioeconomic status were also associated with greater mortality risk. Engaging patients earlier in HIV infection remains critical. PDR may influence short-term mortality and further studies to optimize management will be important in settings with increasing PDR.
format Online
Article
Text
id pubmed-6777822
institution National Center for Biotechnology Information
language English
publishDate 2019
publisher Public Library of Science
record_format MEDLINE/PubMed
spelling pubmed-67778222019-10-13 Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study Silverman, Rachel A. John-Stewart, Grace C. Beck, Ingrid A. Milne, Ross Kiptinness, Catherine McGrath, Christine J. Richardson, Barbra A. Chohan, Bhavna Sakr, Samah R. Frenkel, Lisa M. Chung, Michael H. PLoS One Research Article INTRODUCTION: Despite increased treatment availability, HIV-infected individuals continue to start antiretroviral therapy (ART) late in disease progression, increasing early mortality risk. MATERIALS AND METHODS: Nested prospective cohort study within a randomized clinical trial of adult patients initiating ART at clinics in urban Nairobi and rural Maseno, Kenya, between 2013–2014. We estimated mortality incidence rates following ART initiation and used Cox proportional hazards regression to identify predictors of mortality within 12 months of ART initiation. Analyses were stratified by clinic site to examine differences in mortality correlates and risk by location. RESULTS: Among 811 participants initiated on ART, the mortality incidence rate within a year of initiating ART was 7.44 per 100 person-years (95% CI 5.71, 9.69). Among 207 Maseno and 612 Nairobi participants initiated on ART, the mortality incidence rates (per 100 person-years) were 12.78 (95% CI 8.49, 19.23) and 5.72 (95% CI 4.05, 8.09). Maseno had a 2.20-fold greater risk of mortality than Nairobi (95% CI 1.29, 3.76; P = 0.004). This association remained [adjusted hazard ratio (HR) = 2.09 (95% CI 1.17, 3.74); P = 0.013] when adjusting for age, gender, education, pre-treatment drug resistance (PDR), and CD4 count, but not when adjusting for BMI. In unadjusted analyses, other predictors (P<0.05) of mortality included male gender (HR = 1.74), age (HR = 1.04 for 1-year increase), fewer years of education (HR = 0.92 for 1-year increase), unemployment (HR = 1.89), low body mass index (BMI<18.5 m/kg(2); HR = 4.99), CD4 count <100 (HR = 11.67) and 100–199 (HR = 3.40) vs. 200–350 cells/μL, and pre-treatment drug resistance (PDR; HR = 2.49). The increased mortality risk associated with older age, males, and greater education remained when adjusted for location, age, education and PDR, but not when adjusted for BMI and CD4 count. PDR remained associated with increased mortality risk when adjusted for location, age, gender, education, and BMI, but not when adjusted for CD4 count. CD4 and BMI associations with increased mortality risk persisted in multivariable analyses. Despite similar baseline CD4 counts across locations, mortality risk associated with low CD4 count, low BMI, and PDR was greater in Maseno than Nairobi in stratified analyses. CONCLUSIONS: High short-term post-ART mortality was observed, partially due to low CD4 count and BMI at presentation, especially in the rural setting. Male gender, older age, and markers of lower socioeconomic status were also associated with greater mortality risk. Engaging patients earlier in HIV infection remains critical. PDR may influence short-term mortality and further studies to optimize management will be important in settings with increasing PDR. Public Library of Science 2019-10-04 /pmc/articles/PMC6777822/ /pubmed/31584992 http://dx.doi.org/10.1371/journal.pone.0223411 Text en © 2019 Silverman et al http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Research Article
Silverman, Rachel A.
John-Stewart, Grace C.
Beck, Ingrid A.
Milne, Ross
Kiptinness, Catherine
McGrath, Christine J.
Richardson, Barbra A.
Chohan, Bhavna
Sakr, Samah R.
Frenkel, Lisa M.
Chung, Michael H.
Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study
title Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study
title_full Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study
title_fullStr Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study
title_full_unstemmed Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study
title_short Predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural Kenya: A prospective cohort study
title_sort predictors of mortality within the first year of initiating antiretroviral therapy in urban and rural kenya: a prospective cohort study
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777822/
https://www.ncbi.nlm.nih.gov/pubmed/31584992
http://dx.doi.org/10.1371/journal.pone.0223411
work_keys_str_mv AT silvermanrachela predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT johnstewartgracec predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT beckingrida predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT milneross predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT kiptinnesscatherine predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT mcgrathchristinej predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT richardsonbarbraa predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT chohanbhavna predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT sakrsamahr predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT frenkellisam predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy
AT chungmichaelh predictorsofmortalitywithinthefirstyearofinitiatingantiretroviraltherapyinurbanandruralkenyaaprospectivecohortstudy