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Mortality in patients with HIV-1 infection starting antiretroviral therapy in South Africa, Europe, or North America: a collaborative analysis of prospective studies.

Type of publication Peer-reviewed
Publikationsform Original article (peer-reviewed)
Author Boulle Andrew, Schomaker Michael, May Margaret T, Hogg Robert S, Shepherd Bryan E, Monge Susana, Keiser Olivia, Lampe Fiona C, Giddy Janet, Ndirangu James, Garone Daniela, Fox Matthew, Ingle Suzanne M, Reiss Peter, Dabis Francois, Costagliola Dominique, Castagna Antonella, Ehren Kathrin, Campbell Colin, Gill M John, Saag Michael, Justice Amy C, Guest Jodie, Crane Heidi M, Egger Matthias,
Project Swiss HIV Cohort Study (SHCS)
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Original article (peer-reviewed)

Journal PLoS medicine
Volume (Issue) 11(9)
Page(s) 1001718 - 1001718
Title of proceedings PLoS medicine
DOI 10.1371/journal.pmed.1001718

Open Access

Type of Open Access Publisher (Gold Open Access)


High early mortality in patients with HIV-1 starting antiretroviral therapy (ART) in sub-Saharan Africa, compared to Europe and North America, is well documented. Longer-term comparisons between settings have been limited by poor ascertainment of mortality in high burden African settings. This study aimed to compare mortality up to four years on ART between South Africa, Europe, and North America. Data from four South African cohorts in which patients lost to follow-up (LTF) could be linked to the national population register to determine vital status were combined with data from Europe and North America. Cumulative mortality, crude and adjusted (for characteristics at ART initiation) mortality rate ratios (relative to South Africa), and predicted mortality rates were described by region at 0-3, 3-6, 6-12, 12-24, and 24-48 months on ART for the period 2001-2010. Of the adults included (30,467 [South Africa], 29,727 [Europe], and 7,160 [North America]), 20,306 (67%), 9,961 (34%), and 824 (12%) were women. Patients began treatment with markedly more advanced disease in South Africa (median CD4 count 102, 213, and 172 cells/µl in South Africa, Europe, and North America, respectively). High early mortality after starting ART in South Africa occurred mainly in patients starting ART with CD4 count <50 cells/µl. Cumulative mortality at 4 years was 16.6%, 4.7%, and 15.3% in South Africa, Europe, and North America, respectively. Mortality was initially much lower in Europe and North America than South Africa, but the differences were reduced or reversed (North America) at longer durations on ART (adjusted rate ratios 0.46, 95% CI 0.37-0.58, and 1.62, 95% CI 1.27-2.05 between 24 and 48 months on ART comparing Europe and North America to South Africa). While bias due to under-ascertainment of mortality was minimised through death registry linkage, residual bias could still be present due to differing approaches to and frequency of linkage. After accounting for under-ascertainment of mortality, with increasing duration on ART, the mortality rate on HIV treatment in South Africa declines to levels comparable to or below those described in participating North American cohorts, while substantially narrowing the differential with the European cohorts. Please see later in the article for the Editors' Summary.