Causes of death stratified by HIV status in the post-art era

Abstract

Introduction: To date, HIV and AIDS has claimed the lives of more than 34 million people worldwide. Reports claim that HIV positive patients on antiretroviral therapy (ART) have similar life expectancies to their HIV negative counterparts, but there is a lack of data comparing causes of death between the two groups. This study aimed to describe the causes of death, and more specifically HIV-associated deaths, as reported in a government public tertiary hospital mortuary register. Methods: A cross sectional study of adult deaths reported in the Helen Joseph Hospital (HJH) mortuary register between 2014 and 2017 was performed. The recorded causes of death during six winter and six summer months over the three year period are reported. Causes of death were reported by HIV status (positive, negative and unknown) and CD4 count category (< 200 cells/ml, 200 - 500 cells/ml and > 500 cells/ml) within the 12 months before death. A sub-analysis among HIV positive individuals known to have been on ART was performed to examine factors associated with death from a respiratory illness. Results: A total of 1766 adults (52% male; median age 53.2 years IQR 39.7 - 67.4; 43% HIV positive) were included in the analysis. Overall, infections (n = 416, 23.5%) were the leading cause of death followed by AIDS (n = 215, 14.2%). Similarly, among HIV positive individuals infections (n = 194, 25.7%) and AIDS (n = 172, 22.8%) were the main causes of death. Among HIV negative individuals, infections were the leading cause of death (n = 53, 21.3%), followed by malignancies (n = 31, 12.4%) and heart or vascular illnesses (n = 28, 11.2%). In those with an unknown HIV status, infections were the leading cause of death (n = 169, 22.8 %) followed by heart or vascular illnesses (n = 67, 8.8%) and AIDS (n = 62, 8.1%), suggesting that these individuals were HIV positive. As expected, AIDS was the main cause of death among HIV positive individuals with a low CD4 count (< 200 cells/ml) while heart or vascular illness, bacterial infection, malignancy and renal failure were equally ranked after AIDS among those with a high CD4 count (> 500 cells/ml). Of the HIV positive individuals who could be linked to the electronic ART register and known to be on ART (n = 339), 88% (n = 299) had a viral load reported within months before death. Of these 55% were virally suppressed (n = 163). Individuals who had completed TB treatment in less than a year had a two-fold risk of dying from a respiratory illness (aOR 2.03 95% CI 1.07, 3.83) compared to those who had completed TB treatment in more than one year prior to their death. iv

Discussion: Consistent with other reports bacterial infections and AIDS-related infections, of which TB is the biggest contributor, were the top causes of death between 2014 and 2017. HIV prevalence was lower than other reports possibly due to underreporting of AIDS-related deaths. Poor documentation of HIV status may result in misclassification and further underestimation of AIDS-related deaths. Individuals who have recently completed TB treatment have a high rate of respiratory infection including recurrent TB. It is therefore important to allocate appropriate surveillance resources and monitor HIV positive TB patients during and after TB treatment.