Although people living with HIV should have near normal life expectancy, far too many still die prematurely

Editor’s notes: The scale up of antiretroviral therapy (ART) is the most important development in the past decade of the HIV response.  Not only do antiretroviral medicines prevent death and prevent the immune destruction that HIV causes, but they also prevent transmission to sexual partners.  Nonetheless, the challenges of reaching everyone living with HIV are enormous and Young and colleagues’ study from the city of Nairobi highlights that we still have some distance to go.  The authors estimated that 74% of adults living with HIV were receiving ART and among women, the figure was even higher and was estimated to have reached more than the UNAIDs target of 81%.  The authors collected data from the two largest mortuaries in Nairobi, where most deaths that occur in the city are registered.  With approximately 80% of all deaths in the city being registered, the authors believe that their study is reasonably representative of the adult population of the city. They found that among 807 people who died in Nairobi during the recruitment period, HIV was greatly over-represented.  They calculated that around 16% of adult deaths in the city were attributable to HIV, and that, when adjusted for age and sex, death rates among people living with HIV were more than four times higher than the rate among HIV-negative people.  The authors point out that these proportions and rates are much lower than they were at the peak of the epidemic, but they do show that in Nairobi we still have some distance to go to ensure that people living with HIV have the same life expectancy as those who are HIV-negative.

 

HIV-associated mortality in the era of antiretroviral therapy scale-up – Nairobi, Kenya, 2015

Young PW, Kim AA, Wamicwe J, Nyagah L, Kiama C, Stover J, Oduor J, Rogena EA, Walong E, Zielinski-Gutierrez E, Imbwaga A, Sirengo M, Kellogg TA, De Cock KM. PLoS One. 2017 Aug 2;12(8):e0181837. doi: 10.1371/journal.pone.0181837. eCollection 2017.

Background: Declines in HIV prevalence and increases in antiretroviral treatment coverage have been documented in Kenya, but population-level mortality associated with HIV has not been directly measured. In urban areas where a majority of deaths pass through mortuaries, mortuary-based studies have the potential to contribute to our understanding of excess mortality among HIV-infected persons. We used results from a cross-sectional mortuary-based HIV surveillance study to estimate the association between HIV and mortality for Nairobi, the capital city of Kenya.

Methods and Findings: HIV seropositivity in cadavers measured at the two largest mortuaries in Nairobi was used to estimate HIV prevalence in adult deaths. Model-based estimates of the HIV-infected and uninfected population for Nairobi were used to calculate a standardized mortality ratio and population-attributable fraction for mortality among the infected versus uninfected population. Monte Carlo simulation was used to assess sensitivity to epidemiological assumptions. When standardized to the age and sex distribution of expected deaths, the estimated HIV positivity among adult deaths aged 15 years and above in Nairobi was 20.9% (95% CI 17.7-24.6%). The standardized mortality ratio of deaths among HIV-infected versus uninfected adults was 4.35 (95% CI 3.67-5.15), while the risk difference was 0.016 (95% CI 0.013-0.019). The HIV population attributable mortality fraction was 0.161 (95% CI 0.131-0.190). Sensitivity analyses demonstrated robustness of results.

Conclusions: Although 73.6% of adult PLHIV receive antiretrovirals in Nairobi, their risk of death is four-fold greater than in the uninfected, while 16.1% of all adult deaths in the city can be attributed to HIV infection. In order to further reduce HIV-associated mortality, high-burden countries may need to reach very high levels of diagnosis, treatment coverage, retention in care, and viral suppression.

Abstract [1]  Full-text [free] access [2]

HIV Treatment [4], People living with HIV [5]
Africa [6]
Kenya [7]
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