Longitudinal trends in mortality and its causes among migrant HIV/AIDS patients undergoing antiretroviral therapy compared to their counterparts: a cohort study, 2016–2022 – BMC Public Health

Analysis of Mortality Predictors in HIV-Positive Patients Receiving ART in the Context of Sustainable Development Goals

Executive Summary

A single-center cohort study was conducted to identify predictive factors for mortality among HIV-positive patients on Antiretroviral Therapy (ART). The study, with a total follow-up of 14,263.0 person-years, recorded an overall mortality rate of 7.7%. Multivariate analysis identified several significant predictors of mortality, including migrant status, age, sex, interval from diagnosis to ART initiation, presence of Opportunistic Infections (OIs), Viral Load (VL), Serum Creatinine (SCR) levels, and CD4 cell count. These findings have significant implications for achieving several Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities).

Alignment with SDG 3: Good Health and Well-being

The study’s findings directly inform strategies to meet SDG Target 3.3, which aims to end the epidemic of AIDS by 2030. Achieving this goal requires a deep understanding of the clinical and demographic factors driving mortality.

Key Clinical Determinants of Mortality

Several clinical indicators were identified as critical risk factors for mortality, while others were protective. Effective management of these factors is essential for improving patient survival and advancing public health outcomes.

• Risk Factors for Mortality:
  • ART initiation delayed more than 30 days after diagnosis.
  • Presence of Opportunistic Infections (OIs).
  • High Viral Load (VL).
  • Abnormal Serum Creatinine (SCR) levels, indicating renal dysfunction.
• Protective Factor Against Mortality:
  • A CD4 cell count greater than 200 cells/µl.

The data confirms that timely ART initiation, control of OIs, viral suppression, and preservation of immune and renal function are paramount in reducing AIDS-related deaths. These elements form the cornerstone of effective HIV management programs aligned with SDG 3.

Addressing Inequalities in Health Outcomes (SDG 10 & SDG 5)

The research highlights significant disparities in mortality risk based on migratory status, gender, and age, underscoring the need for targeted interventions to ensure equitable healthcare access and outcomes, in line with SDG 10 (Reduced Inequalities) and SDG 5 (Gender Equality).

Disparities Between Migrant and Non-Migrant Populations

The study revealed complex outcomes for migrant populations, who face unique challenges and demonstrate different health-seeking behaviors. Addressing these disparities is crucial for fulfilling the SDG 10 mandate to reduce inequality within and among countries.

• Mortality Risk: Migrant patients receiving ART had a 36% lower risk of death compared to non-migrant patients, potentially due to a stronger desire for treatment to avoid social stigma in their hometowns.
• Treatment Adherence Challenges: Despite lower mortality, migrant populations exhibited a slightly higher loss-to-follow-up rate and face greater risks of treatment interruption due to mobility, transportation barriers, and limited social support.
• Demographics: The migrant cohort was predominantly male and aged 25–49 years, representing a demographically active segment of the population.

Gender and Age-Based Disparities

Significant differences in mortality were observed across gender and age groups, highlighting vulnerabilities that must be addressed to achieve SDG 5 and ensure no one is left behind.

• Gender Inequality: Female patients had a significantly lower mortality risk than male patients. This aligns with national data showing escalating male-to-female mortality ratios, potentially due to accelerated disease progression and suboptimal clinical engagement in males.
• Age-Related Risk: Individuals aged 50 years and older had a higher risk of death compared to younger patients (18–24 years), reflecting age-associated disease progression as HIV transitions into a chronic condition.

Policy Recommendations for Inclusive and Sustainable Healthcare Systems (SDG 11 & SDG 16)

Based on the finding that migrants can achieve better treatment outcomes under the right conditions, the study proposes policy enhancements to build resilient and inclusive healthcare infrastructure, contributing to SDG 11 (Sustainable Cities and Communities) and SDG 16 (Peace, Justice and Strong Institutions).

Proposed Strategies to Enhance Care for Mobile Populations

To optimize healthcare delivery and ensure continuity of care for migrant populations, the following strategies are recommended:

1. Establish Centralized Care Hubs: Develop specialized HIV care centers in major migration destination cities to provide continuous and expert access to ART.
2. Strengthen Inter-City Referral Systems: Implement shared electronic medical records to facilitate seamless care transitions for patients moving between cities.
3. Implement Tailored Outreach Programs: Design programs that address migrant-specific barriers by offering flexible clinic hours, mobile health reminders, and peer navigation services to improve engagement and adherence.

Future Research Directions

To further inform targeted interventions and policy, future research should focus on standardizing the definition of migrant populations and integrating socioeconomic factors to fully clarify the impact of mobility on HIV-related mortality. This data-driven approach is essential for creating effective and equitable health systems capable of meeting the Sustainable Development Goals.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being: The article’s core focus is on public health, specifically investigating the predictive factors for mortality among HIV-positive patients. It discusses disease management, treatment outcomes (mortality rates), access to healthcare (Antiretroviral Therapy – ART), and the clinical progression of HIV/AIDS, all of which are central to ensuring healthy lives and promoting well-being.
• SDG 5: Gender Equality: The article explicitly analyzes and highlights significant disparities in health outcomes between sexes. It notes that “female patients had a significantly lower mortality risk than male patients” and cites data showing “male-to-female mortality ratios escalating from 1.98 (2001) to 2.99 (2016).” This focus on gender-based differences in disease progression and mortality directly relates to achieving gender equality in health.
• SDG 10: Reduced Inequalities: The study is fundamentally an analysis of inequality in health outcomes. It compares different population groups, primarily focusing on the disparities between “migrant and non-migrant populations.” It also examines inequalities based on age and sex, stating that “migrant status, age, sex” are significant predictors of mortality. The policy recommendations aim to reduce these inequalities by improving healthcare access for mobile populations.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Under SDG 3 (Good Health and Well-being):
   • Target 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases…” The article directly contributes to this target by analyzing mortality from AIDS and identifying key factors (e.g., timely ART initiation, viral suppression, high CD4 counts) that are critical to reducing AIDS-related deaths and ultimately ending the epidemic.
   • Target 3.8: “Achieve universal health coverage, including… access to quality essential health-care services…” The article discusses barriers and facilitators to accessing healthcare, particularly for migrant populations. It highlights issues like “loss-to-follow-up,” “transportation barriers,” and “mobility-related interruptions,” and proposes solutions like “centralized care hubs” and “inter-city referral systems” to improve continuous access to ART, which is an essential healthcare service.
2. Under SDG 5 (Gender Equality):
   • Target 5.c: “Adopt and strengthen sound policies… for the promotion of gender equality…” While not proposing specific gender-focused policies, the article’s detailed analysis of higher mortality rates in males and the potential reasons (“accelerated disease progression, suboptimal treatment response… and clinical engagement challenges in male patients”) provides the evidence base needed to develop policies that address these gender-specific health disparities.
3. Under SDG 10 (Reduced Inequalities):
   • Target 10.2: “By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex… origin… or other status.” The article examines health outcomes based on status (migrant vs. non-migrant), age, and sex, identifying specific groups at higher risk. The discussion of “social discrimination against HIV/AIDS patients” and challenges faced by migrants points to issues of social inclusion that impact health.
   • Target 10.3: “Ensure equal opportunity and reduce inequalities of outcome…” The entire study is centered on identifying and explaining inequalities of outcome (i.e., mortality). It compares mortality risks between different groups and proposes policy enhancements to create more equitable health outcomes for mobile populations.
   • Target 10.7: “Facilitate orderly, safe, regular and responsible migration and mobility of people, including through the implementation of planned and well-managed migration policies.” The article’s policy recommendations, such as creating “centralized care hubs in major migration destination cities” and “strengthening inter-city referral systems,” are direct examples of well-managed policies designed to facilitate the mobility of people while ensuring their health needs are met.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article mentions several specific quantitative and qualitative indicators that can be used to measure progress:

• Overall Mortality Rate: The article explicitly states an “overall mortality rate of 7.7%,” which is a direct indicator for measuring progress in ending the AIDS epidemic (Target 3.3).
• Disaggregated Mortality Data: The study uses mortality rates disaggregated by various factors, which serve as indicators for inequality (Target 10.3). These include:
  • Mortality risk by migrant status (migrant vs. non-migrant).
  • Mortality risk by sex, including specific “male-to-female mortality ratios” (Target 5.c).
  • Mortality risk by age group (e.g., “individuals aged ≥ 50 years had a higher risk of death”).
• Healthcare Access and Quality Indicators: The article implies several indicators related to universal health coverage (Target 3.8):
  • Interval from diagnosis to ART initiation: The study identifies “ART initiation > 30 days after diagnosis” as a risk factor, making this time interval a key performance indicator for timely care.
  • Loss-to-follow-up rate: This is mentioned as a metric to assess continuity of care, noting it was “slightly higher than that among non-migrant populations.”
• Clinical Health Outcome Indicators: These are used to measure the effectiveness of treatment and patient health status (relevant to Target 3.3):
  • CD4 cell count: A count “> 200 cells/µl” is identified as a protective factor.
  • Viral Load (VL): “High VL” is cited as a risk factor for mortality.
  • Presence of Opportunistic Infections (OIs): The presence of OIs is correlated with higher mortality rates.
  • Serum Creatinine (SCR) levels: Used as a biomarker for renal function, with “abnormal SCR levels” identified as a risk factor.

4. Table of SDGs, Targets, and Indicators

Source: bmcpublichealth.biomedcentral.com