Predictors of Survival among Adult Ethiopian Patients in the National ART Program at Seven University Teaching Hospitals A Prospective Cohort Study

Abstract

Background: In Ethiopia, the publicly funded antiretroviraltreatment (ART) program was started in 2005. Two hundredseventy-five thousand patients were enrolled in the national ARTprogram by 2012. However, there is limited data on mortality andpredictors of death among adult patients in the ART program. Thestudy aimed to estimate mortality and risk factors for death amongadult, ART-naïve patients, started in the national ART programfrom January 2009 to July 2013.Methods : Multi-site, prospective, observational cohort study ofadult, age > 18 years, ART-naïve patients, started in the nationalART program at seven university-affiliated hospitals from January2009 - July 2013. Kaplan-Meier and Cox regression analyses wereused to estimate survival and determine risk factors for death.Results : A total of 976 patients, 594 females (60.9 %), wereenrolled into the study. Median age of the cohort was 33years. Themedian CD4 count at start of ART was 144 cells/μl (interquartilerange (IQR) 78-205), and 34.2% (330/965) had CD4 < 100. Sixty-three percent (536/851) had viral load greater than 5 log copies/ml(IQR 4.7-5.7) at base line. One hundred and one deaths wererecorded during follow-up period, all-cause mortality rate 10.3%;5.4 deaths/100 person years of observation, 95% confidenceinterval 4.4-6.5. Seventy percent of the deaths occurred within sixmonths of starting ART. Cox regression analyses showed that thefollowing measures independently predicted mortality: age >51years, (Adjusted Hazard Ratio (AHR) 4.01, P=0.003), WHO stagesIII&IV, (AHR 1.76, p = 0.025), CD4 count, <100, (AHR 2.36, p=0.006), and viral load >5 log copies /ml (CHR 1.71, p = 0.037).Conclusion : There is high early on- ART mortality in patientspresenting with advanced immunodeficiency. Detecting cases andinitiating ART before onset of advanced immunodeficiency mightimprove survival.