title: Estimation of mortality among HIV-infected people on antiretroviral treatment in East Africa: a sampling based approach in an observational, multisite, cohort study.
abstract: Mortality in HIV-infected people after initiation of antiretroviral treatment (ART) in resource-limited settings is an important measure of the effectiveness and comparative effectiveness of the global public health response. Substantial loss to follow-up precludes accurate accounting of deaths and limits our understanding of effectiveness. We aimed to provide a better understanding of mortality at scale and, by extension, the effectiveness and comparative effectiveness of public health ART treatment in east Africa.
  
  
  
  In 14 clinics in five settings in Kenya, Uganda, and Tanzania, we intensively traced a sample of patients randomly selected using a random number generator, who were infected with HIV and on ART and who were lost to follow-up (>90 days late for last scheduled visit). We incorporated the vital status outcomes for these patients into analyses of the entire clinic population through probability-weighted survival analyses.
  
  
  
  We followed 34 277 adults on ART from Mbarara and Kampala in Uganda, Eldoret, and Kisumu in Kenya, and Morogoro in Tanzania. The median age was 35 years (IQR 30-42), 11 628 (34%) were men, and median CD4 count count before therapy was 154 cells per μL (IQR 70-234). 5780 patients (17%) were lost to follow-up, 991 (17%) were selected for tracing between June 10, 2011, and Aug 27, 2012, and vital status was ascertained for 860 (87%). With incorporation of outcomes from the patients lost to follow-up, estimated 3 year mortality increased from 3·9% (95% CI 3·6-4·2) to 12·5% (11·8-13·3). The sample-corrected, unadjusted 3 year mortality across settings was lowest in Mbarara (7·2%) and highest in Morogoro (23·6%). After adjustment for age, sex, CD4 count before therapy, and WHO stage, the sample-corrected hazard ratio comparing the settings with highest and lowest mortalities was 2·2 (95% CI 1·5-3·4) and the risk difference for death at 3 years was 11% (95% CI 5·0-17·7).
  
  
  
  A sampling-based approach is widely feasible and important to an understanding of mortality after initiation of ART. After adjustment for measured biological drivers, mortality differs substantially across settings despite delivery of a similar clinical package of treatment. Implementation research to understand the systems, community, and patients' behaviours driving these differences is urgently needed.
  
  
  
  The US National Institutes of Health and President's Emergency Fund for AIDS Relief.
authors.affiliation: Division of HIV/AIDS at San Francisco General Hospital in the Department of Medicine, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium. Electronic address: genge@php.ucsf.edu.
authors.forename: Elvin H
authors.initials: EH
authors.lastname: Geng
authors.affiliation: Kenya Medical Research Institute and the Family AIDS Care and Education Services Program, Kisumu, Kenya; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Odeny
authors.affiliation: National AIDS Control Program, Dar Es Salaam, Tanzania; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Rita E
authors.initials: RE
authors.lastname: Lyamuya
authors.affiliation: Infectious Diseases Institute, Kampala, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Alice
authors.initials: A
authors.lastname: Nakiwogga-Muwanga
authors.affiliation: College of Health Sciences, School of Medicine, Department of Medicine, Moi University, Eldoret, Kenya; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Lameck
authors.initials: L
authors.lastname: Diero
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Mwebesa
authors.initials: M
authors.lastname: Bwana
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Winnie
authors.initials: W
authors.lastname: Muyindike
authors.affiliation: College of Health Sciences, School of Medicine, Department of Medicine, Moi University, Eldoret, Kenya; Department of Medicine, School of Medicine, Indiana University School of Public Health, Indiana University, Indianapolis, IN, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.affiliation: National AIDS Control Program, Dar Es Salaam, Tanzania; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Geoffrey R
authors.initials: GR
authors.lastname: Somi
authors.affiliation: Infectious Diseases Institute, Kampala, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Andrew
authors.initials: A
authors.lastname: Kambugu
authors.affiliation: Kenya Medical Research Institute and the Family AIDS Care and Education Services Program, Kisumu, Kenya; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.affiliation: Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Megan
authors.initials: M
authors.lastname: Wenger
authors.affiliation: Department of Medicine, School of Medicine, Indiana University School of Public Health, Indiana University, Indianapolis, IN, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Kara K
authors.initials: KK
authors.lastname: Wools-Kaloustian
authors.affiliation: Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: David V
authors.initials: DV
authors.lastname: Glidden
authors.affiliation: Department of Biostatistics, Indiana University School of Public Health, Indiana University, Indianapolis, IN, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Constantin T
authors.initials: CT
authors.lastname: Yiannoutsos
authors.affiliation: Division of HIV/AIDS at San Francisco General Hospital in the Department of Medicine, University of California, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Martin
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003625:Data Collection / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology / Q000401:mortality*; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008297:Male; D012494:Sampling Studies; D013636:Tanzania / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology; D014481:United States; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents