ART Understanding the causes of death among HIV/AIDS patients commencing ART in Karonga district

Despite many gains earned by the provision of ART a good proportion of HIV infected patients still die within three months of initiation of ART. The reasons for this are not clear but include: continued risk of serious co-infection prior to recovery of immunity; intensification and detrimental inflammation with immune reconstitution (IRIS: immune reconstitution inflammatory syndrome); drug reactions; and/or ART started beyond the point of the bodies ability to recover. The clinical progression of HIV-infection is dominated by a relatively small number of frequent clinical syndromes resulting from opportunistic infections with specific aetiological agents. In Africa the commonest opportunistic infections are: Mycobacterium tuberculosis, Streptococcus pneumoniae, Cryptococcus neoformans, non-typhoidal Salmonella, human herpes virus 8, and Plasmodium falciparum. Many of these co-infections are preventable. How much each of these specific pathogens contributes to this early death and whether specific prophylaxis should be put in place is not clear. Careful clinical description backed up by quality controlled diagnostic services will help to define the role of these co-infections during the early phase of ART
One successfully established on ART, failure will occur when ART resistance develops. This is not inevitable but the factors that lead to resistance are incompletely understood. Long term follow-up of individuals with careful assessment of drug adherence, co-infections, viral resistance and other clinical parameters will help to define targets for interventions to prolong the effective life of first line and subsequent ART.
This study aimed to establish a cohort of HIV positive individuals eligible for ART and follow them with detailed clinical assessments and laboratory work in order to understand the determinants of death, co-infections (clinical failure) and virological failure while on ART in a rural Malawian population.
Patients at ART clinics in the DSS area and Karonga district hospital (and later patients at pre-ART clinic before universal test and treat was implemented) were interviewed to gather information and link their clinic ID to their DSS ID. Clinic data were gathered from paper registers through digital photos of the register or from electronic records.
NHSRC approval number: 448
Funded by Wellcome Trust 079828/Z/06/Z and 096249/Z/11/A