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Estimated mortality of adult HIV-infected patients starting treatment with combination antiretroviral therapy
  1. Constantin Theodore Yiannoutsos1,
  2. Leigh Francis Johnson2,
  3. Andrew Boulle2,
  4. Beverly Sue Musick1,
  5. Thomas Gsponer3,
  6. Eric Balestre4,
  7. Matthew Law5,
  8. Bryan E Shepherd6,
  9. Matthias Egger3,
  10. for the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration
  1. 1Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
  2. 2Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
  3. 3Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
  4. 4ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Universitè Bordeaux, Bordeaux, France
  5. 5The Kirby Institute, University of New South Wales, Sydney, Australia
  6. 6Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
  1. Correspondence to Professor Constantin Theodore Yiannoutsos, Department of Biostatistics, Indiana University School of Medicine, 410 West 10th Street, Suite 3000, Indianapolis, IN 46202, USA; cyiannou{at}


Objective To provide estimates of mortality among HIV-infected patients starting combination antiretroviral therapy.

Methods We report on the death rates from 122 925 adult HIV-infected patients aged 15 years or older from East, Southern and West Africa, Asia Pacific and Latin America. We use two methods to adjust for biases in mortality estimation resulting from loss from follow-up, based on double-sampling methods applied to patient outreach (Kenya) and linkage with vital registries (South Africa), and apply these to mortality estimates in the other three regions. Age, gender and CD4 count at the initiation of therapy were the factors considered as predictors of mortality at 6, 12, 24 and >24 months after the start of treatment.

Results Patient mortality was high during the first 6 months after therapy for all patient subgroups and exceeded 40 per 100 patient years among patients who started treatment at low CD4 count. This trend was seen regardless of region, demographic or disease-related risk factor. Mortality was under-reported by up to or exceeding 100% when comparing estimates obtained from passive monitoring of patient vital status.

Conclusions Despite advances in antiretroviral treatment coverage many patients start treatment at very low CD4 counts and experience significant mortality during the first 6 months after treatment initiation. Active patient tracing and linkage with vital registries are critical in adjusting estimates of mortality, particularly in low- and middle-income settings.

  • AIDS
  • Clinical Care (General)
  • Epidemiology (General)
  • HIV Clinical Care

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Funding This work was supported by UNAIDS through a grant to CTY, BSM, LFJ, AB, TG, EB and ME. In addition, the data collection was funded by the NIH National Institute of Allergies and infectious Diseases (NIAID), through grants AI069911 (East Africa), 2U01AI069924 (Southern Africa), AI069919 (West Africa), AI069907 (Asia Pacific) and AI069923 (Latin America).

  • Competing interests None.

  • Ethics approval Secondary analysis of anonymous primary clinical data.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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