A retrospective study of survival and risk factors for mortality among people living with HIV who received antiretroviral treatment in a resource-limited setting

BACKGROUND: The availability and accessibility of effective antiretroviral therapy (ART) for people living with HIV (PLWH) has substantially improved in the past two decades in resource-limited settings. Therefore, evaluation of survival is needed in the current setting. METHOD: We retrospectively analyzed secondary data of the national AIDS program database from national health security region number 4 among PLWH who were ART-naive between January 2014 and December 2018. All PLWH were followed until December 2019 to evaluate their survival status and possible risk factors related to death. RESULTS: A total of 42,229 PLWH were identified, of which 14,053 were ART-naive and thus enrolled in the study. Sixty-seven percent were male, the mean ± SD age was 35 ± 12 years, and the median (IQR) baseline CD4 count was 162 (44–353) cells/mm(3). Regarding medical care benefits, 46% had a universal health coverage scheme, 34% had a national social security scheme, and 2% had a civil servants medical benefit scheme. A total of 2142 (15%) mortalities occurred during the total follow-up period of 28,254 patient-years. The mortality rate was 7.5 (95% CI 7.2–7.9) per 100 person-years. Survival rates at 1, 2, 3, 4 and 5 years after HIV registration were 88.2% (95% CI 87.6–88.7%), 85.3% (95% CI 84.6–85.9%), 82.9% (95% CI 81.9–83.4%), 81.3% (95% CI 80.5–82.0%) and 75.1% (95% CI 73.5–76.8%), respectively. The Cox proportional hazards model showed that all-cause mortality was associated with a history of ART switching (HR = 7.06, 95% CI 4.53–11.00), major opportunistic infections during ART (HR = 1.93, 95% CI 1.35–2.77), baseline CD4 count ≤ 200 vs. > 500 cells/mm3 (HR = 4.00, 95% CI 1.45–11.11), age ≥ 50 vs. < 30 years (HR = 1.77, 95% CI 1.12–2.78), and receiving nevirapine-based regimens(HR = 1.43, 95% CI 1.04–1.97). CONCLUSIONS: This study demonstrated the substantial mortality rate over the consecutive 5 years of the follow-up period among PLWH who received ART in a resource-limited setting. Early case finding and prompt initiation of ART as well as continuous HIV care are a cornerstone to improve survival.