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Socioeconomic Determinants of Mortality in HIV: Evidence From a Clinical Cohort in Uganda

Burkey, Matthew D. MD, MPH*; Weiser, Sheri D. MD, MA, MPH; Fehmie, Desiree MPH, MSc; Alamo-Talisuna, Stella MD§; Sunday, Pamella MS§; Nannyunja, Joy§; Reynolds, Steven J. MD‖,¶; Chang, Larry W. MD, MPH¶,#

JAIDS Journal of Acquired Immune Deficiency Syndromes: May 1st, 2014 - Volume 66 - Issue 1 - p 41–47
doi: 10.1097/QAI.0000000000000094
Clinical Science

Objective: To delineate the association between baseline socioeconomic status (SES) indicators and mortality and lost to follow-up (LTFU) in a cohort of HIV-infected individuals enrolled in antiretroviral therapy (ART) in urban Uganda.

Design: Retrospective cohort study nested in an antiretroviral clinic-based cohort.

Methods: SES indicators including education, employment status, and a standardized wealth index, and other demographic and clinical variables were assessed at baseline among ART-treated patients in a clinic-based cohort in Kampala, Uganda. Confirmed mortality (primary outcome) and LTFU (secondary outcome) were actively ascertained over a 4-year follow-up period from 2005 to 2009.

Results: Among 1763 adults [70.5% female; mean age, 36.2 years (SD = 8.4)] enrolled in ART, 14.4% (n = 253) were confirmed dead and 19.7% (n = 346) were LTFU at 4-year follow-up. No formal education [adjusted odds ratio (AOR) 1.76; 95% confidence interval (CI): 1.19 to 2.59], having fewer than 6 dependents (AOR 1.39; 95% CI: 1.04 to 1.86), unemployment (AOR 1.98; 95% CI: 1.48 to 2.66), and housing tenure index score (a component of the wealth index) (AOR 1.11; 95% CI: 1.00 to 1.23) were significantly associated with confirmed mortality at 4 years. SES indicators were not associated with LTFU at 4 years.

Conclusions: Baseline SES indicators, including education, number of dependents, employment status, and components of a standard wealth index may indicate long-term vulnerability to mortality in patients with HIV/AIDS, despite uniform access to ART. Future studies delineating the pathways through which poverty and limited assets affect clinical outcomes may lead to more effective HIV interventions in low-resource settings.

*Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD;

Division of HIV/AIDS and Center for AIDS Prevention Studies, University of California, San Francisco, CA;

The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH;

§Reach Out-Mbuya, Kampala, Uganda;

Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD;

Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD; and

#Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Correspondence to: Matthew D. Burkey, MD, MPH, Johns Hopkins Hospital, 1800 Orleans Street, Bloomberg 12352, Baltimore, MD 21287 (e-mail:

M.D.B. was supported by a grant from the Johns Hopkins Center for Global Health to conduct this study. L.W.C. was supported by the National Institute of Mental Health (5K23MH086338). S.J.R. was supported by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health. S.D.W was supported by the National Institute of Mental Health (R01MH095683) and the Burke Family Foundation.

The authors have no conflicts of interest to disclose.

Received July 18, 2013

Accepted December 09, 2013

© 2014 by Lippincott Williams & Wilkins