A decade of antiretroviral therapy in Uganda: what are the emerging causes of death?

摘要

BackgroundThe roll out of antiretroviral therapy (ART) in Sub-Saharan Africa led to a decrease in mortality [1]. AIDS-related deaths have fallen by 48% since the peak in 2005 [2]. The UNAIDS 2016 global report shows gains in treatment of HIV positive persons were responsible for a 26% decline in AIDS-related deaths from an estimate of 1.5 million [1.3 million – 1.7million] persons in 2010, to 1.1 million [940,000–1.3million] in 2015 [3]. While in developed countries ART has been available for more than 20?years [4], in Sub-Saharan Africa ART has been available for slightly over a decade. The first countries to roll out ART, such as Malawi, begun in 2003 [5, 6]. In Uganda, ART was initially rolled out in 2004 and targeted severely immune compromised patients enrolled in HIV care [7].The success of ART roll out in sub-Saharan Africa has been undermined by high mortality, especially in the first year after starting ART [8]. This high mortality was highest or similar to pre-ART mortality in the first months of ART and largely driven by opportunistic infections, especially tuberculosis, Cryptococcal meningitis and sepsis [8].However, there is limited information on the specific causes of death among patients on long term ART in Sub-Saharan Africa. The recent audit of global deaths by the World Health Organization and Global Burden of Disease reported several causes of death, of which HIV was listed among the top 10 causes in 2006 [9]. In our work we aim to disaggregate this further to describe the causes of death among HIV positive persons in SSA. We also previously described mortality in only the first three years in a research cohort of patients started on treatment during the initial roll out of ART. Our results showed that the most common causes of early mortality were tuberculosis and Cryptococcal meningitis [10].In this study, we sought to explore the trends and causes of death over time during the first 10?years of follow up among a well-characterized cohort of patients, with emphasis in estimating HIV-related and non-HIV related mortality rates. In addition, the causes of death described here are over a ten-year period, as many have been described among shorter duration. Information reported on causes of death will be useful for comparison with other African cohorts that rolled out ART around the same time. We hypothesized that there would be a decrease in HIV-related deaths over time.