sábado, 8 de septiembre de 2012

PLoS Medicine: Gender Differences in Survival among Adult Patients Starting Antiretroviral Therapy in South Africa: A Multicentre Cohort Study

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PLoS Medicine: Gender Differences in Survival among Adult Patients Starting Antiretroviral Therapy in South Africa: A Multicentre Cohort Study

Gender Differences in Survival among Adult Patients Starting Antiretroviral Therapy in South Africa: A Multicentre Cohort Study

Morna Cornell1*, Michael Schomaker1, Daniela Belen Garone2, Janet Giddy3, Christopher J. Hoffmann4, Richard Lessells5, Mhairi Maskew6, Hans Prozesky7, Robin Wood8, Leigh F. Johnson1, Matthias Egger1,9, Andrew Boulle1, Landon Myer1, for the International Epidemiologic Databases to Evaluate AIDS Southern Africa (IeDEA-SA) Collaboration
1 Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa, 2 Médecins sans Frontières, Cape Town, South Africa, 3 McCord Hospital, Durban, South Africa, 4 Aurum Institute, Johannesburg, South Africa and Johns Hopkins University School of Medicine, 5 Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa, 6 Health Economics & Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, 7 Division of Infectious Diseases, Department of Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa, 8 The Desmond Tutu HIV Centre, Institute for Infectious Disease & Molecular Medicine, University of Cape Town, Cape Town, South Africa, 9 Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland

Abstract Top


Increased mortality among men on antiretroviral therapy (ART) has been documented but remains poorly understood. We examined the magnitude of and risk factors for gender differences in mortality on ART.

Methods and Findings

Analyses included 46,201 ART-naïve adults starting ART between January 2002 and December 2009 in eight ART programmes across South Africa (SA). Patients were followed from initiation of ART to outcome or analysis closure. The primary outcome was mortality; secondary outcomes were loss to follow-up (LTF), virologic suppression, and CD4+ cell count responses. Survival analyses were used to examine the hazard of death on ART by gender. Sensitivity analyses were limited to patients who were virologically suppressed and patients whose CD4+ cell count reached >200 cells/µl. We compared gender differences in mortality among HIV+ patients on ART with mortality in an age-standardised HIV-negative population.
Among 46,201 adults (65% female, median age 35 years), during 77,578 person-years of follow-up, men had lower median CD4+ cell counts than women (85 versus 110 cells/µl, p<0 .001=".001" 77="77" be="be" classified="classified" em="em" iii="iii" likely="likely" more="more" stage="stage" to="to" versus="versus" were="were" who="who">p
<0 .001=".001" 5.7="5.7" and="and" crude="crude" deaths="deaths" em="em" had="had" higher="higher" in="in" mortality="mortality" person-years="person-years" versus="versus">p<0 .001=".001" 0.86="0.86" 1.04="1.04" 1.12="1.12" 1.20="1.20" 1.22="1.22" 1.31="1.31" 36="36" 95="95" account="account" across="across" adjusted="adjusted" african="african" after="after" age-standardised="age-standardised" all="all" an="an" analyses="analyses" analysis="analysis" and="and" appeared="appeared" art="art" baseline="baseline" be="be" better="better" but="but" by="by" characteristics="characteristics" ci="ci" cohorts="cohorts" consistent="consistent" data="data" death="death" did="did" die="die" differences="differences" directly="directly" disease="disease" eight="eight" findings="findings" for="for" gender="gender" had="had" hazard="hazard" hiv-negative="hiv-negative" hiv="hiv" immunologic="immunologic" in="in" increasing="increasing" likely="likely" limited="limited" located.="located." ltf="ltf" men.="men." men="men" missing="missing" months="months" more="more" mortality.="mortality." mortality="mortality" non-hiv="non-hiv" not="not" notably="notably" observe="observe" observed="observed" of="of" on="on" over="over" p="p" participating="participating" population.="population." populations="populations" programmes.="programmes." proportion="proportion" rates="rates" ratio="ratio" responses="responses" similar="similar" slightly="slightly" smaller="smaller" south="south" suppression="suppression" than="than" the="the" time="time" to="to" truly="truly" virologic="virologic" was="was" we="we" were="were" where="where" women="women">


HIV-infected men have higher mortality on ART than women in South African programmes, but these differences are only partly explained by more advanced HIV disease at the time of ART initiation, differential LTF and subsequent mortality, and differences in responses to treatment. The observed differences in mortality on ART may be best explained by background differences in mortality between men and women in the South African population unrelated to the HIV/AIDS epidemic.
Please see later in the article for the Editors' Summary.

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