Context: AIDSRelief, a PEPFAR-funded HIV implementing partner in Rwanda, supports 20 health facilities in Nyamasheke and Burera Districts. In published African cohort studies, mortality was between 8% and 26% after 8-12 months on ART. Risk factors for early mortality were nadir low CD4 cell counts and advanced disease (WHO stage 4). In Rwanda no data is available on ART mortality. We propose to review mortality of HIV patients on ART in 2 district hospitals (DHs) as a quality care improvement process.
Methods: A retrospective chart review of all patients who died after ART initiation occurring from June 2004 to October 2009 in 2 DHs was performed.
Results: Since 2004, 2,302 patients started ART in the 2 DHs, of which 191 died (8.2%). Of these, 179 charts were reviewed: 52% were male and 55% were between 30 and 49 years old. At enrolment, 60% had WHO stage 3 diseases, while 62% had baseline CD4 less than 200 cells/mm3 and 40% less than 100 cells/mm3. Fifty percent of the deaths occurred within the first 3 months and 61% within 6 months after ART initiation. In 67% of cases, the cause of death was unknown or not documented, and diagnosed opportunistic infections (OIs) were found in a minority of patients: only 1 case of PCP, 5 cases of cryptoccocal meningitis and 7 cases of TB were documented. No diagnoses of IRIS or therapeutic failure were noted.
Conclusions: The majority of continuing mortality in ART patients in these 2DHs occurs soon after initiation of ART. Early death after ART starts with 62% of deaths having baseline CD4 below 200 cells/mm3 suggest that undiagnosed OIs and/or IRIS could be responsible for ongoing mortality. Improved OI screening before and after initiation of ART and close follow-up of patients with low CD4 count at baseline are recommended.
(C) 2012 Lippincott Williams & Wilkins, Inc.