The paper was the result of joint research of the International Epidemiologic Databases to Evaluate AIDS Southern African (IeDEA-SA) collaboration of Southern African HIV cohort studies and the Antiretroviral Therapy Cohort Collaboration (ART-CC) of European and North American HIV cohort studies. The ART-CC is led by Professor Jonathan Sterne and Dr Margaret May from the University of Bristol School of Social and Community Medicine.
The researchers compared data from four cohorts in South Africa (30,467 adults), six in North America (7,160 adults), and nine in Europe (29,727 adults) in which individuals were followed for up to four years after starting ART.
After correcting for under-ascertainment of mortality in patients who were lost to cohort follow up in South Africa, through linkage to a population register, , the researchers found that after one year of treatment, the South African cohorts had higher mortality than North American or European cohorts. This was likely to be as a result of the immune systems of South African patients having sustained more HIV-induced damage by the time the patients started treatment.
However, for individuals on ART for between two and four years, the mortality rates in North America were comparable to or higher than those for South Africa. After making adjustment for differences such as gender and stage of HIV at the time of starting treatment disease, the researchers estimated mortality rate ratios between 24 and 48 months on ART to be 0.46 (95% confidence interval [CI] 0.37–0.58) comparing Europe to South Africa, and 1.62 (95% CI 1.27–2.05) comparing North America to South Africa.
Prof Jonathan Sterne said: “These results show that the benefits of antiretroviral therapy can be achieved by health systems in low as well as high income settings. They also demonstrate the importance of access to and quality of health care, patient characteristics, and presence of co-morbidities such as infection with hepatitis C, in determining outcomes of care in people living with HIV.”
This is the first comparison of mortality up to four years after starting ART between high-income countries and a high-HIV burden setting in Southern Africa with near-complete ascertainment of mortality.
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