title: Mortality and loss to follow-up among HIV-infected persons on long-term antiretroviral therapy in Latin America and the Caribbean.
abstract: BACKGROUND
  Long-term survival of HIV patients after initiating highly active antiretroviral therapy (ART) has not been sufficiently described in Latin America and the Caribbean, as compared to other regions. The aim of this study was to describe the incidence of mortality, loss to follow-up (LTFU) and associated risk factors for patients enrolled in the Caribbean, Central and South America Network (CCASAnet).
  
  
  METHODS
  We assessed time from ART initiation (baseline) to death or LTFU between 2000 and 2014 among ART-naïve adults (≥18 years) from sites in seven countries included in CCASAnet: Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru. Kaplan-Meier techniques were used to estimate the probability of mortality over time. Risk factors for death were assessed using Cox regression models stratified by site and adjusted for sex, baseline age, nadir pre-ART CD4 count, calendar year of ART initiation, clinical AIDS at baseline and type of ART regimen.
  
  
  RESULTS
  A total of 16,996 ART initiators were followed for a median of 3.5 years (interquartile range (IQR): 1.6-6.2). The median age at ART initiation was 36 years (IQR: 30-44), subjects were predominantly male (63%), median CD4 count was 156 cells/µL (IQR: 60-251) and 26% of subjects had clinical AIDS prior to starting ART. Initial ART regimens were predominantly non-nucleoside reverse transcriptase inhibitor based (86%). The cumulative incidence of LTFU five years after ART initiation was 18.2% (95% confidence interval (CI) 17.5-18.8%). A total of 1582 (9.3%) subjects died; the estimated probability of death one, three and five years after ART initiation was 5.4, 8.3 and 10.3%, respectively. The estimated five-year mortality probability varied substantially across sites, from 3.5 to 14.0%. Risk factors for death were clinical AIDS at baseline (adjusted hazard ratio (HR)=1.65 (95% CI 1.47-1.87); p<0.001), lower baseline CD4 (HR=1.95 (95% CI 1.63-2.32) for 50 vs. 350 cells/µL; p<0.001) and older age (HR=1.47 (95% CI 1.29-1.69) for 50 vs. 30 years at ART initiation; p<0.001).
  
  
  CONCLUSIONS
  In this large, long-term study of mortality among HIV-positive adults initiating ART in Latin America and the Caribbean, overall estimates of mortality were heterogeneous, generally falling between those reported in high-income countries and sub-Saharan Africa.
authors.affiliation: Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru; gabriela.carriquiry.c@upch.pe; gabriela.carriquiry@yahoo.com.
authors.forename: Gabriela
authors.initials: G
authors.lastname: Carriquiry
authors.affiliation: Fundación Huésped, Buenos Aires, Argentina.
authors.forename: Valeria
authors.initials: V
authors.lastname: Fink
authors.affiliation: Department of Medicine, Vanderbilt University Nashville, TN, USA.
authors.forename: John Robert
authors.initials: JR
authors.lastname: Koethe
authors.affiliation: Department of Biostatistics, Vanderbilt University Nashville, TN, USA.
authors.forename: Mark Joseph
authors.initials: MJ
authors.lastname: Giganti
authors.affiliation: Department of Medicine, Vanderbilt University Nashville, TN, USA.
authors.forename: Karu
authors.initials: K
authors.lastname: Jayathilake
authors.affiliation: Department of Biostatistics, Vanderbilt University Nashville, TN, USA.
authors.forename: Meridith
authors.initials: M
authors.lastname: Blevins
authors.affiliation: Fundación Huésped, Buenos Aires, Argentina.
authors.forename: Pedro
authors.initials: P
authors.lastname: Cahn
authors.affiliation: Instituto de Pesquisa Clinica Evandro Chagas-Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.affiliation: Fundación Arriarán, Santiago, Chile.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Wolff
authors.affiliation: Le Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, Port-au-Prince, Haiti.|Weill Cornell Medical College, New York, NY, USA.
authors.forename: Jean William
authors.initials: JW
authors.lastname: Pape
authors.affiliation: Instituto Hondureño de Seguridad Social and Hospital Escuela, Tegucigalpa, Honduras.
authors.forename: Denis
authors.initials: D
authors.lastname: Padgett
authors.affiliation: Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico.
authors.forename: Juan Sierra
authors.initials: JS
authors.lastname: Madero
authors.affiliation: Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Gotuzzo
authors.affiliation: Department of Medicine, Vanderbilt University Nashville, TN, USA.
authors.forename: Catherine Carey
authors.initials: CC
authors.lastname: McGowan
authors.affiliation: Department of Biostatistics, Vanderbilt University Nashville, TN, USA.
authors.forename: Bryan Earl
authors.initials: BE
authors.lastname: Shepherd
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D017691:Caribbean Region; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality; D006801:Humans; D007843:Latin America; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models
keywords: AIDS; ART; HIV; Latin America; long-term mortality; the Caribbean