Predictors of All-Cause Mortality Among People With Human Immunodeficiency Virus (HIV) in a Prospective Cohort Study in East Africa and Nigeria
Authors: Kibuuka Hannah , Musingye Ezra , Mwesigwa Betty , Semwogerere Michael , Iroezindu Michael , Bahemana Emmanuel , Maswai Jonah , Owuoth John , Esber Allahna , Dear Nicole , Crowell Trevor A , Polyak Christina S , Ake Julie A ,   AFRICOS Study Group, Reynolds Alexus , Song Katherine , Milazzo Mark , Francisco Leilani , Schech Steven , Omar Badryah , Mebrahtu Tsedal , Lee Elizabeth , Bohince Kimberly , Parikh Ajay , Hern Jaclyn , Duff Emma , Lombardi Kara , Imbach Michelle , Anne Eller Leigh , Kibuuka Hannah , Semwogerere Michael , Naluyima Prossy , Zziwa Godfrey , Tindikahwa Allan , Nakazzi Bagenda Claire , Mutebe Hilda , Kafeero Cate , Baghendaghe Enos , Lwebuge William , Ssentogo Freddie , Birungi Hellen , Tegamanyi Josephine , Wangiri Paul , Nabanoba Christine , Namulondo Phiona , Tumusiime Richard , Musingye Ezra , Nanteza Christina , Wandege Joseph , Waiswa Michael , Najjuma Evelyn , Maggaga Olive , Kato Kenoly Isaac , Mukanza Barbara , Maswai Jonah , Langat Rither , Ngeno Aaron , Korir Lucy , Langat Raphael , Opiyo Francis , Kasembeli Alex , Ochieng Christopher , Towett Japhet , Kimetto Jane , Omondi Brighton , Leelgo Mary , Obonyo Michael , Rotich Linner , Tonui Enock , Chelangat Ella , Kapkiai Joan , Wangare Salome , Bett Kesi Zeddy , Ngeno Janet , Langat Edwin , Labosso Kennedy , Rotich Joshua , Cheruiyot Leonard , Changwony Enock , Bii Mike , Chumba Ezekiel , Ontango Susan , Gitonga Danson , Kiprotich Samuel , Ngtech Bornes , Engoke Grace , Metet Irene , Airo Alice , Kiptoo Ignatius , Owuoth John , Sing’oei Valentine , Rehema Winne , Otieno Solomon , Ogari Celine , Modi Elkanah , Adimo Oscar , Okwaro Charles , Lando Christine , Onyango Margaret , Aoko Iddah , Obambo Kennedy , Meyo Joseph , Suja George , Iroezindu Michael , Adamu Yakubu , Azuakola Nnamdi , Asuquo Mfreke , Bolaji Tiamiyu Abdulwasiu , Kokogho Afoke , Sani Mohammed Samirah , Okoye Ifeanyi , Odeyemi Sunday , Suleiman Aminu , Umeji Lawrence C , Enas Onome , Ayogu Miriam , Chigbu-Ukaegbu Ijeoma , Adai Wilson , Anayochukwu Odo Felicia , Abdu Rabi , Akiga Roseline , Nwandu Helen , Sylvestina Okolo Chisara , Taiwo Ogundele , Oche Ben Otene , Innocent Eigege Nicholas , Ibrahim Musa Tony , Chibuzor Joseph Juliet , Okeke Ndubuisi C , Parker Zahra , Elizabeth Harrison Nkechinyere , Concilia Agbaim Uzoamaka , Ademola Adegbite Olutunde , Linus Asogwa Ugochukwu , Adelakun Adewale , Ekeocha Chioma , Idi Victoria , Eluwa Rachel , Titilayo Nwalozie Jumoke , Faith Igiri , Irekpitan Wilson Blessing , Elemere Jacinta , Nnadi Nkiru , Falaju Idowu Francis , Rosemary Ndubuisi , Natalie Uzeogwu Amaka , Owanza Obende Theresa , Lauretta Obilor Ifeoma , Emekaili Doris , Akinwale Edward , Ochai Inalegwu , Maganga Lucas , Bahemana Emmanuel , Khamadi Samoel , Njegite John , Lueer Connie , Kisinda Abisai , Mwamwaja Jaquiline , Mbwayu Faraja , David Gloria , Mwaipopo Mtasi , Gervas Reginald , Mkondoo Dorothy , Somi Nancy , Kiliba Paschal , Mwalongo Ephrasia , Mwaisanga Gwamaka , Msigwa Johnisius , Mfumbulwa Hawa , Edwin Peter , Olomi Willyhelmina 
Published: December 2021

Abstract

Background
Introduction of antiretroviral therapy (ART) has been associated with a decline in human immunodeficiency virus (HIV)-related mortality, although HIV remains a leading cause of death in sub-Saharan Africa. We describe all-cause mortality and its predictors in people living with HIV (PLWH) in the African Cohort Study (AFRICOS).

Methods
AFRICOS enrolls participants with or without HIV at 12 sites in Kenya, Uganda, Tanzania, and Nigeria. Evaluations every 6 months include sociobehavioral questionnaires, medical history, physical examination, and laboratory tests. Mortality data are collected from medical records and survivor interviews. Multivariable Cox proportional hazards models were used to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for factors associated with mortality.

Results
From 2013 through 2020, 2724 PLWH completed at least 1 follow-up visit or experienced death. Of these 58.4% were females, 25.8% were aged ≥ 50 years, and 98.3% were ART-experienced. We observed 11.42 deaths per 1000 person-years (95% CI: 9.53–13.68) with causes ascertained in 54% of participants. Deaths were caused by malignancy (28.1%), infections (29.7%), and other non-HIV related conditions. Predictors of mortality included CD4 ≤ 350 cells/µL (aHR 2.01 [95% CI: 1.31–3.08]), a log10copies/mL increase of viral load (aHR 1.36 [95% CI: 1.22–1.51]), recent fever (aHR 1.85[95% CI: 1.22–2.81]), body mass index &lt; 18.5 kg/m2 (aHR 2.20 [95% CI: 1.44–3.38]), clinical depression (aHR 2.42 [95% CI: 1.40–4.18]), World Health Organization (WHO) stage III (aHR 2.18 [95% CI: 1.31–3.61]), a g/dL increase in hemoglobin (aHR 0.79 [95% CI: .72–.85]), and every year on ART (aHR 0.67 [95% CI: .56–.81]).

Conclusions
The mortality rate was low in this cohort of mostly virally suppressed PLWH. Patterns of deaths and identified predictors suggest multiple targets for interventions to reduce mortality.