title: Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries.
abstract: BACKGROUND
  Highly active antiretroviral therapy (HAART) is being scaled up in developing countries. We compared baseline characteristics and outcomes during the first year of HAART between HIV-1-infected patients in low-income and high-income settings.
  
  
  METHODS
  18 HAART programmes in Africa, Asia, and South America (low-income settings) and 12 HIV cohort studies from Europe and North America (high-income settings) provided data for 4810 and 22,217, respectively, treatment-naïve adult patients starting HAART. All patients from high-income settings and 2725 (57%) patients from low-income settings were actively followed-up and included in survival analyses.
  
  
  RESULTS
  Compared with high-income countries, patients starting HAART in low-income settings had lower CD4 cell counts (median 108 cells per muL vs 234 cells per muL), were more likely to be female (51%vs 25%), and more likely to start treatment with a non-nucleoside reverse transcriptase inhibitor (NNRTI) (70%vs 23%). At 6 months, the median number of CD4 cells gained (106 cells per muL vs 103 cells per muL) and the percentage of patients reaching HIV-1 RNA levels lower than 500 copies/mL (76%vs 77%) were similar. Mortality was higher in low-income settings (124 deaths during 2236 person-years of follow-up) than in high-income settings (414 deaths during 20,532 person-years). The adjusted hazard ratio (HR) of mortality comparing low-income with high-income settings fell from 4.3 (95% CI 1.6-11.8) during the first month to 1.5 (0.7-3.0) during months 7-12. The provision of treatment free of charge in low-income settings was associated with lower mortality (adjusted HR 0.23; 95% CI 0.08-0.61).
  
  
  CONCLUSIONS
  Patients starting HAART in resource-poor settings have increased mortality rates in the first months on therapy, compared with those in developed countries. Timely diagnosis and assessment of treatment eligibility, coupled with free provision of HAART, might reduce this excess mortality.
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: Martin W G
authors.initials: MW
authors.lastname: Brinkhof
authors.forename: François
authors.initials: F
authors.lastname: Dabis
authors.forename: Mauro
authors.initials: M
authors.lastname: Schechter
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.forename: Paolo
authors.initials: P
authors.lastname: Miotti
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Christian
authors.initials: C
authors.lastname: Laurent
authors.forename: Eduardo
authors.initials: E
authors.lastname: Sprinz
authors.forename: Catherine
authors.initials: C
authors.lastname: Seyler
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.forename: Eric
authors.initials: E
authors.lastname: Balestre
authors.forename: Jonathan A C
authors.initials: JA
authors.lastname: Sterne
authors.forename: Margaret
authors.initials: M
authors.lastname: May
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
mesh_terms: D000293:Adolescent; D000328:Adult; D000553:Ambulatory Care / Q000191:economics*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D016208:Databases, Factual; D003906:Developing Countries / Q000191:economics*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D015497:HIV-1; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D019562:Viral Load