Mortality of HIV-infected patients in low-income countries

Abstract

Paula Braitstein and colleagues present convincingly the crucial piece of evidence in favour of antiretroviral therapy (ART)-ie, that it works well in settings where it is needed most. Encouraging is their finding that the adjusted mortality of HIV-infected patients receiving ART in low-income countries, barring the first 2 months, is comparable to that in high-income countries. However, a note of caution is warranted before arriving at this conclusion. On one hand it is well known that the absolute CD4 cell counts of healthy HIV-negative individuals in south Asia and Africa, especially Botswana, Nigeria, and Ethiopia, are substantially lower than those of their western counterparts.2, 3 Also known is that, despite this fact, the rate of decline in CD4 counts is proportionately slower, and the rate of disease progression is no different in these individuals.4 However, we do not know whether or not the low CD4 count engenders the same quantum of risk for opportunistic infections as in developed countries. On the other hand, HIV-negative individuals from Uganda, Kenya, and Côte d'Ivoire have higher absolute CD4 counts than those from developed countries.5 Therefore, when comparing the HIV-related mortality of patients from low-income and high-income countries, adjusting for baseline CD4 count without taking into account the interethnic variations in CD4 counts would result in considerable uncertainty of the estimates in either direction. One has to be aware of the possibility that the adjusted hazard ratios for the mortality of patients receiving ART in low-income countries might in fact be higher than that reported by Braitstein and colleagues. We declare that we have no conflict of interest.