Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study.
BACKGROUND
Antiretroviral therapy (ART) is increasingly available in Africa, but physicians and clinical services are few. We therefore assessed the effect of a home-based ART programme in Uganda on mortality, hospital admissions, and orphanhood in people with HIV-1 and their household members.


METHODS
In 2001, we enrolled and followed up 466 HIV-infected adults and 1481 HIV-uninfected household members in a prospective cohort study. After 5 months, we provided daily co-trimoxazole (160 mg trimethoprim and 800 mg sulfamethoxazole) prophylaxis to HIV-infected participants. Between May, 2003, and December, 2005, we followed up 138 infected adults who were eligible and 907 new HIV-infected participants and their HIV-negative household members in a study of ART (mainly stavudine, lamivudine, and nevirapine). Households were visited every week by lay providers, and no clinic visits were scheduled after enrolment. We compared rates of death, hospitalisation, and orphanhood during different study periods and calculated the number needed to treat to prevent an outcome.


RESULTS
233 (17%) of 1373 participants with HIV and 40 (1%) of 4601 HIV-uninfected household members died. During the first 16 weeks of ART and co-trimoxazole, mortality in HIV-infected participants was 55% lower than that during co-trimoxazole alone (14 vs 16 deaths per 100 person-years; adjusted hazard ratio 0.45, 95% CI 0.27-0.74, p=0.0018), and after 16 weeks, was reduced by 92% (3 vs 16 deaths per 100 person-years; 0.08, 0.06-0.13, p<0.0001). Compared with no intervention, ART and co-trimoxazole were associated with a 95% reduction in mortality in HIV-infected participants (5 vs 27 deaths per 100 person-years; 0.05, 0.03-0.08, p<0.0001), 81% reduction in mortality in their uninfected children younger than 10 years (0.2 vs 1.2 deaths per 100 person-years; 0.19, 0.06-0.59, p=0.004), and a 93% estimated reduction in orphanhood (0.9 vs 12.8 per 100 person-years of adults treated; 0.07, 0.04-0.13, p<0.0001).


CONCLUSIONS
Expansion of access to ART and co-trimoxazole prophylaxis could substantially reduce mortality and orphanhood among adults with HIV and their families living in resource-poor settings.
Mermin
Jonathan
J
Centers for Disease Control and Prevention-Uganda, Global AIDS Program, National Center for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Entebbe, Uganda. jhm7@cdc.gov
Were
Willy
W
Ekwaru
John Paul
JP
Moore
David
D
Downing
Robert
R
Behumbiize
Prosper
P
Lule
John R
JR
Coutinho
Alex
A
Tappero
Jordan
J
Bunnell
Rebecca
R
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D002648:Child; D046688:Child Mortality; D054540:Child, Orphaned / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality; D018023:HIV Seronegativity / Q000187:drug effects; D015497:HIV-1; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011446:Prospective Studies; D015996:Survival Rate; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use*; D014454:Uganda / Q000453:epidemiology
D019380:Anti-HIV Agents; D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination