Mortality after ART starts remains higher in women in Americas and Africa than in Europe
22nd International AIDS Conference, Amsterdam, Netherlands, July 23-27, 2018


Mark Mascolini

All-cause mortality after women start antiretroviral therapy (ART) proved persistently higher through 4 years of follow-up in South and Central America, the Caribbean, and sub-Saharan Africa than in Europe in an analysis of more than 190,000 women [1]. In all regions except North America, mortality compared with Europe was highest in the first 3 months of ART then reached stable but still-higher levels from 3 months through 4 years of follow-up.

Researchers working with 4 large observational cohorts conducted this analysis of all-cause mortality after ART begins and by duration of ART in women living with HIV in Europe, the Americas, and sub-Saharan Africa. Follow-up extended through 48 months after ART began. The analysis involved 5 IeDEA regions (East, West, and Southern Africa; North America; and Latin American/Caribbean) and 40 observational cohorts from COHERE in EuroCord. Participants were treatment-naive women starting ART in 2000-2014 at age 18 to 80 years. All women were infected through injecting drugs or sex. 

The investigators ascertained mortality through cohort data and mortality registries. They divided women into 7 regions: Europe, East Africa, West Africa, Southern Africa, South America, North America, and Central America and the Caribbean. They calculated mortality in 5 periods after ART initiation: 0-3 months, 3-6 months, 6-12 months, 12-24 months, and 24-48 months. Finally, the investigators calculated mortality rate ratios comparing mortality in study regions to mortality in Europe after adjusting for age, CD4 count, and period of ART initiation.

The study group included 190,175 women, 47% in East Africa, 19% in Southern Africa, 16% in Europe, 13% in West Africa, 3% in North America, 2% in Central America/Caribbean, and 1% in South America. Age when ART began ranged from 33 years in Southern Africa to 40 in North America. CD4 counts when ART began lay close to 250 in Europe and North America, at 141 in Southern Africa, and between 170 and 190 in other regions. 

Proportions of women infected with HIV while injecting drugs were highest in North America (18%) and Europe (7%). North America had a higher proportion of black women than Europe (63% versus 26%). 

Crude all-cause mortality fell substantially in the first 6 months of ART in every region except Europe and North America, which had substantially lower initial mortality than the other regions.

Compared with Europe, mortality rate ratios in the first 3 months of ART were 4.5 to 10 times higher in all other regions except North America: 9.92 in Central America/Caribbean, 8.95 in West Africa, 7.25 in East Africa, 5.42 in Southern Africa, and 4.47 in South America. 

Mortality rate ratios comparing these 5 regions with Europe declined to stable levels across the on-ART study periods but always remained higher in these regions than in Europe. From month 24 to 48, mortality rate ratios compared with Europe were 5.61 in West Africa, 3.63 in East Africa, 3.47 in Southern Africa, 2.50 in Central America/Caribbean, and 2.42 in South America. In contrast, the mortality rate ratio comparing North America with Europe rose from 0.88 in months 0-3 of ART to 1.25 in months 3-6, 2.30 in months 6-12, 3.40 in months 12-24, and 3.72 in months 24-48.

Reference
Jarrin I, for Global Mortality Disparities in Women Working Group for IeDEA, EuroSIDA, CASCADE, and COHERE in EuroCoord. Mortality differences after ART initiation in HIV-positive women from Europe, the Americas and sub-Saharan Africa; 2000-2014. AIDS 2018: 22nd International AIDS Conference, Amsterdam, Netherlands, July 23-27, 2018. Abstract TUPDC0101.