Understanding high ongoing HIV-associated mortality in the era of antiretroviral therapy in the Western Cape Province of South Africa

Boulle, Andrew

Understanding high ongoing HIV-associated mortality in the era of antiretroviral therapy in the Western Cape Province of South Africa

Monday, 18 August 2014: 4:30 PM

Ballroom C (Dena'ina Center)

Andrew Boulle , University of Cape Town, Observatory, South Africa

Nesbert Zinyakatira, MS , Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa

Juliet Evans, PhD , Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa

Margaret Osler, MPH , University of Cape Town, Observatory, South Africa

David Coetzee, MD , University of Cape Town, Observatory, South Africa

Pamela Groenewald, MD , Medical Research Council of South Africa, Tygerberg, South Africa

Johann Daniels, MPH , City of Cape Town, Cape Town, South Africa

Juanita Arendse, MPH , Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa

Debbie Bradshaw, PhD , Medical Research Council of South Africa, Tygerberg, South Africa

Tracey Naledi, MD , Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa

INTRODUCTION: HIV continues to be the leading cause of premature mortality in South Africa despite aggressive scaling up of antiretroviral treatment (ART). It is unknown if this is due to failure of diagnosis, treatment initiation or treatment itself. We aimed to retrospectively examine prior care in HIV-associated adult deaths in the Western Cape Province (population ≈6 million) in 2012.

METHODS: Deaths with HIV recorded as the primary or underlying cause of death on routine death certification were linked to laboratory and ART information systems. Previous viral load tests or ART register entries denoted prior treatment, while a previous CD4 count denoted diagnosis and linkage to care.

RESULTS: In 2012 HIV was a primary or secondary cause of death in 3161 adults who could be linked to provincial health identifiers (out of a total 3370 HIV-associated and 38695 adult deaths overall), with a median age of 38, and 51% being women. 1243 (39%) had previously been on ART for a median 423 days (interquartile range 86-1043). A quarter of these had last received treatment more than 6 months previously. The median last recorded CD4 count in patients dying after ART initiation was 102 (37-227) cells/µl compared to 97 (32-228) in the 1118 (35%) who had never been on ART but had previously been linked to care. In the latter group 79% had a first CD4 count below 350 cells/µl, half more than 90 days prior to death. The last CD4 count prior to death was substantially lower in men (86 versus 156).

CONCLUSIONS: High ongoing HIV-associated mortality in the Western Cape is due in almost equal measure to the failure to: diagnose and link patients to care; initiate treatment; or retain patients on successful treatment. There are many instances of missed opportunities to initiate or sustain treatment in patients who subsequently die.