Prognostic models have previously been developed for patients infected with HIV-1 who start combination antiretroviral therapy (ART) in high-income countries, but these were not applicable to patients in sub-Saharan Africa.

The researchers, led by Dr Margaret May of the University of Bristol's Department of Social Medicine, developed two prognostic models to identify risk factors for death in patients starting ART in sub-Saharan Africa.  They analysed data for 11,000 adult patients who started ART in Cote d’Ivoire, South Africa, and Malawi between 2004 to 2007.  Both models accurately predict early mortality in patients starting ART in sub-Saharan Africa compared with observed data.

The first model took into account CD4 cell count, WHO clinical disease stage, bodyweight, age, and sex.  The other model replaced CD4 cell count with total lymphocyte count and severity of anaemia because CD4 cell count is not routinely measured in many African ART programmes.

The researchers found that 8.2 per cent of patients died in the first year of ART.   Mortality at 1 year ranged from less than 1 to over 50 per cent, depending on patients’ risk factors when they started ART.  Higher mortality was strongly associated with lower baseline CD4 cell count, more advanced clinical disease stage and severe anaemia. Other independent risk factors for mortality were low total lymphocyte count, older age, and male sex.

Dr May said: “Expected prognosis when ART is started is of great importance to patients with HIV-1 and their doctors, and for planning of health-service provision and treatment guidelines.  The World Health Organization estimates that between 2.7 and 3.1 million people started ART in sub-Saharan Africa by the end of 2008 so having accurate prognostic models for the region is crucial.  Expansion of public health strategies to allow early access to ART in sub-Saharan Africa is also urgently needed.”    

Paper

‘Prognosis of patients with HIV-1 infection starting antiretroviral therapy in sub-Saharan Africa: a collaborative analysis of scale-up programmes’ by Margaret May, Andrew Boulle, Sam Phiri, Eugene Messou, Landon Myer, Robin Wood, Olivia Keiser, Jonathan A C Sterne, Francois Dabis, Matthias Egger, for IeDEA southern Africa and west Africa The Lancet Vol 375

The research was funded by the US National Institute of Allergy and Infectious Diseases, UK Medical Research Council, the National Cancer Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.