Predictors of Mortality among HIV Patients on HAART in an ART Centre – A Retrospective Study

Introduction: The primary goal of highly active antiretroviral therapy (HAART) is to reduce mortality and morbidity rates among HIV-infected people, and to improve their quality of life. As of May 2015, a total of 8, 69,576 HIV/AIDS patient are receiving free Antiretroviral Therapy (ART), in our country despite which, there has been high HIV prevalence and mortality in certain areas. The objective of this retrospective study was to determine the factors associated with mortality in patients on ART under routine programme conditions in an ART centre in Southern Odisha. Methods: Data of HIV positive patients under HAART in the ART centre during April 2014 to March 2015 time period were collected and analysed for various demographic variables, clinical profile and mortality. Results: A total of 956 patients were under HAART during the study period, of which 204 (21.33 %) expired. Even though in majority of patients who died [193 (94.6%)] ART was initiated early; only 56 (27.45%) were under regular treatment; 73 (35.8%) had missed (irregular) doses, 75 (36.8%) were lost to follow up (LFU). Majority (88.24%) of the deaths occurred in the first six months of therapy in patients who had associated tuberculosis or some other AIDs related complications. Conclusion: The study reveals poor survival during the study period in spite of no delay in ART initiation. The increasing number of missed dose cases and LFU cases early after initiation of therapy suggests immediate need to intensify the patient retrieval and counselling services in this region.

to HIV patients.But in spite of all these measures, Ganjam district under this ART Centre has high HIV prevalence in contrast to the National Prevalence showing a steady decline.Over 1,310 people have lost their lives on account of AIDS while a significant number of people are living with HIV (According to reports of Orissa State AIDS Control Society (OSACS) -by Express News Service -published 15 th July 2014).Though a large number of patients have access to HAART through National Programme, there is paucity of data to document the outcome of ART in terms of survival or its determinants.A study done in a centre from the north showed a mortality of 12 per cent at two years 1 and a retrospective cohort analysis from another ART centre showed mortality rate at one year to be 7.66 deaths/100 patient-years with > 50 per cent of the deaths occurring during the first three months of ART initiation 2 , Age, sex, educational status, place of residence, WHO clinical stage, CD4, haemoglobin, nutrition, functional status, and opportunistic infections have been associated with mortality among patients on ART. 3 Strengthening adherence and measures to curtail loss to follow up are important challenges for the ART roll-out programme in India. 4Regular assessment of associated risk factors and record keeping of the mortality data among patients on HAART is important to determine the effectiveness and impact of the ART program.An understanding of the prognostic factors in high-risk individuals will pave way for tailored follow up and better-targeted interventions, and thus improve survival.In this context, the present study was done to identify the factors associated with mortality in HIV-infected patients taking HAARTs in an ART centre in Southern Odisha.

Objective:
1. To analyse the mortality outcome of the HIV-infected patients on antiretroviral treatment in ART Centre.2. To identify the determinants associated with mortality among the HIV-infected patients on antiretroviral treatment in ART Centre.Statistical analysis: The extracted data was presented as frequency with their respective percentages for categorical variables.The main outcome variable was death and the time of its occurrence during the one year period.The predictor variables used in the analysis were gender, CD4 count; ART drugs intake status (Regular/ Missed/ LFU), delay in ART initiation and presence of co-infections.Chi-square test was used to find out any significant association between the above variables.The above analyses were performed on exclusion of the LFU cases.P < 0.05 was considered to be statistically significant.(IBM SPSS Statistics 20.0 software)

RESULTS
A total of 956 patients were under HAART during the study period

DISCUSSION
One of the predictors of mortality most commonly reported [6][7][8][9][10][11] is the time of enrolment into the ART care.Ignorance about the disease and screening programmes, social stigma and discrimination, large scale migration are some reasons why in our setup patients report to the ART centre in advanced stages of disease.The present study showed that, during the year 2014-15, the mortality in patients on ART was high among those initiated on treatment the same year compared to those initiated on treatment during the previous nine years.We have not International Journal of Medicine and Public Health, Vol 6, Issue 4, Oct-Dec, 2016 shown the data about the time of imitation of ART to the number of deaths in the same years, for 2006 to 2013.However, according to this study, though there was no delay in ART treatment (2014-2015), 88.24% of the deaths occurred in the first six months of therapy, indicating a very high early mortality in our patients.There are some studies showing that, patients starting HAART in resource-poor settings have increased mortality rates in the first months on therapy, compared with those in developed countries. 12Several other studies in the developed and low-and middle-income countries also demonstrated that that the survival of HIV-infected patients on ART depends on sex, age, viral load, CD4 count, total lymphocytes, body mass index (BMI) or bodyweight (kg), WHO clinical stage, co-trimoxazole preventive therapy (CPT), haemoglobin, adherence, and nutritional support. 13,14 ale sex was an important risk factor associated with mortality in this study, which has also been reported by another study from our country. 15It was observed that in majority of patients the cause of death was due to TB related severity or AIDs related severity corroborating with other literatures, which report that the risk of death in co-infected individuals is twice that of HIV infected individuals without TB, even when CD4 cell count and antiretroviral therapy are taken into account. 16Further, strict adherence to ART has been associated with a higher chance of survival of HIV infected patients. 17,18 ost important finding in our study was a high lost to follow up cases (36.8%) and patients with missed / irregular doses (35.8%) which were also documented in other studies from India. 19,20 st LFU also occurred within first three months and these patients also had significantly low CD4 count.Even though many studies as cited above, have proved male sex, low CD4 count, co-infections, adherence to HAART, or other factors to be associated with mortality we could not predict them to be associated with mortality in the present study because of the limitations like analysis of death cases of only one year duration and exclusion of LFU cases from the analysis.To conclude, poor survival in spite of early ART initiation, a number of missed dose cases and LFU cases as revealed from the present study suggests immediate need to intensify the patient retrieval and counselling services in this region.

Figure 1 :
Figure 1: Year of initiation of ART among cases that died between 2014-15 5t was a retrospective study conducted in October 2015 in the ART centre of MKCG Medical College, Berhampur, Ganjam, and Odisha.The study was approved by the Institutional Ethics Committee.Following necessary approvals, data was collected from the ART medical record register.The study population included all HIV positive patients, and on HAART in the ART centre (as per Revised NACO guidelines 2009) during April 2014 to March 2015.5Relevantinformation of patients who were under HAART during April 2014-March 2015 were collected from record since the date of initiation of HAART.Utmost care was taken to maintain the confidentiality of the documents.Information with regard to demographic characteristics, number of deaths, cause of death, duration since initiation of ART, adherence to treatment, CD4 values at the time of death was collected from ART register and retrospective analysis of various parameters associated with death was carried out.

Table 2 : Death analysis of On-ART patients in ART Centre
39%) had CD4 count <250 and twenty-one (41.17%) persons had associated co-infections with an equal number of cases (41.17%) showing no adherence to treatment.Chi-square analysis showed a significant association between year of initiation of ART, gender, CD4 count and adherence to treatment.(Table-3)Further odds ratio (OR) with confidence interval (CI) was computed to find out if the above factors are determinants of mortality among patients on ART which revealed that