Risk factors for early mortality among HIV-positive adults on antiretroviral therapy in Ethiopian health facilities – Nature

Report on Early Mortality Factors Among ART Users in Woliso, Ethiopia, in the Context of Sustainable Development Goals

Executive Summary

This report details a historical cohort study conducted in the Woliso district of Ethiopia to identify factors associated with early mortality among 720 Antiretroviral Therapy (ART) users between January 2018 and December 2022. The findings are critical for evaluating progress towards Sustainable Development Goal 3 (SDG 3), specifically Target 3.3, which aims to end the AIDS epidemic by 2030. The study revealed a significant mortality incidence density of 5.1 per 100 person-years. Key predictors of early mortality were identified, highlighting socio-economic and clinical vulnerabilities that impede the achievement of universal health coverage and equitable health outcomes as outlined in the SDGs. The results underscore the urgent need for targeted interventions to support high-risk populations, strengthen health systems, and ensure no one is left behind in the national HIV response.

• Being divorced: Adjusted Hazard Ratio (AHR) of 6.34
• Advanced WHO clinical stage (III/IV): AHR of 2.92
• Suboptimal ART adherence: AHR of 5.48 for fair adherence and 3.50 for poor adherence

The high early mortality rate necessitates enhanced strategies for early HIV care enrollment and strict treatment adherence to accelerate progress towards SDG 3.

1.0 Introduction: HIV/AIDS Response and the Sustainable Development Agenda

The global effort to combat the HIV/AIDS epidemic is a cornerstone of the 2030 Agenda for Sustainable Development, primarily encapsulated within SDG 3: Good Health and Well-being. Target 3.3 explicitly calls for an end to the AIDS epidemic. Antiretroviral Therapy (ART) is the primary tool for achieving this goal, having dramatically reduced AIDS-related deaths globally. Ethiopia has made significant strides in expanding ART access, contributing to this global objective. However, variable survival rates and high early mortality among people living with HIV (PLHIV) on ART present a substantial challenge to realizing SDG 3. This report analyzes the predictors of mortality in Ethiopia’s Woliso district to provide evidence-based insights for strengthening health systems and creating targeted interventions that align with the principles of SDG 10 (Reduced Inequalities) and SDG 5 (Gender Equality).

2.0 Methodology

2.1 Study Design and Population

A historical cohort study was conducted from April 1 to April 30, 2023, analyzing data from 720 randomly selected adult HIV-positive individuals who initiated ART between January 1, 2018, and December 30, 2022. The study was set in three public health facilities in the Waliso district, Southwest Shoa Zone, Oromia Regional State, Ethiopia.

2.2 Data Collection and Analysis

Data were collected from patient records using the Open Data Kit (ODK). Statistical analysis was performed using STATA 13. The primary outcome was time-to-death, measured in months from ART initiation. Key analytical methods included:

1. Kaplan–Meier survival analysis to estimate survival probabilities.
2. Cox proportional hazards regression to identify predictors of mortality.

Variables with a P-value

3.0 Key Findings

3.1 Cohort Characteristics

The study cohort of 720 patients had a mean age of 37.7 years, with a majority being female (57.5%) and residing in urban areas (58.6%). At the time of ART initiation:

• Functional Status: 83.3% were classified as working.
• WHO Clinical Stage: 66.1% were in WHO clinical stage I.
• ART Adherence: 80.7% demonstrated good adherence during the follow-up period.
• Prophylaxis: 74% received isoniazid preventive therapy (INH) and 62.9% received cotrimoxazole preventive therapy (CPT).

3.2 Survival and Mortality Outcomes

Over a 60-month follow-up period, the cohort was observed for 1,294.67 person-years. The overall mortality incidence density was 5.1 per 100 person-years.

• Total deaths recorded: 66 (9.2% of the cohort).
• Early mortality was high, with 30.3% of deaths (20 individuals) occurring within the first six months of ART initiation.
• 34.8% of all deaths occurred within the first 12 months.
• The cumulative survival probability at the end of the 60-month follow-up was 61.76%.

3.3 Significant Predictors of Mortality

Multivariable Cox regression analysis identified four statistically significant predictors of mortality. These factors highlight specific vulnerabilities that directly challenge the achievement of equitable health outcomes under SDG 3 and SDG 10.

1. Marital Status: Divorced individuals had a 6.34 times higher hazard of death compared to single individuals (AHR: 6.34; 95% CI: 2.05–19.65). This points to social and gender-based inequalities impacting health, relevant to SDG 5.
2. WHO Clinical Stage: Patients in advanced WHO clinical stage III or IV at baseline were nearly three times more likely to die than those in stage I or II (AHR: 2.92; 95% CI: 1.12–8.27). This underscores the importance of early diagnosis and treatment for achieving SDG 3.3.
3. ART Adherence: Suboptimal adherence was a strong predictor of mortality. Compared to good adherence, the hazard of death was 5.48 times higher for fair adherence (AHR: 5.48; 95% CI: 2.37–12.66) and 3.50 times higher for poor adherence (AHR: 3.50; 95% CI: 1.72–7.09). This highlights the need for robust patient support systems, a key component of SDG 3.8 (Universal Health Coverage).
4. Age: Individuals over 45 years had a 2.49 times higher hazard of death compared to their younger counterparts (AHR: 2.49; 95% CI: 1.33–4.69).

4.0 Discussion: Implications for Achieving Sustainable Development Goals

The study’s findings reveal critical barriers to achieving SDG 3.3 in Ethiopia. The high incidence of early mortality (5.1 per 100 person-years) indicates that while ART access has expanded, patient survival remains a significant challenge. This mortality rate, particularly within the first six months of treatment, suggests that many individuals are entering care at an advanced stage of disease, undermining efforts to ensure healthy lives for all.

The disproportionately high mortality risk among divorced individuals, particularly women, highlights the intersection of health with social determinants and gender inequality, directly relating to SDG 5 and SDG 10. Divorce can lead to loss of social and economic support, increased stigma, and psychological distress, which negatively impact treatment adherence and overall health outcomes. Addressing these inequalities is essential for an effective and equitable HIV response.

The strong correlation between poor adherence, advanced disease stage, and mortality emphasizes the need to strengthen health systems in line with SDG 3.8. Achieving universal health coverage requires not only providing access to medicines but also ensuring continuous, high-quality care, including adherence support, counseling, and early diagnosis to prevent disease progression.

5.0 Conclusion and Recommendations for SDG-Aligned Interventions

5.1 Conclusion

The high early mortality rate among ART users in the Woliso district is a significant public health concern that directly impedes progress towards ending the AIDS epidemic as mandated by SDG 3.3. Mortality is driven by a combination of clinical factors (advanced disease stage), behavioral factors (poor adherence), and social determinants (divorced marital status), which reflect deeper systemic inequalities.

5.2 Recommendations

To accelerate progress towards the SDGs, particularly SDG 3, SDG 5, and SDG 10, the following actions are recommended:

1. Strengthen Early Diagnosis and Linkage to Care: Health facilities must intensify efforts to diagnose HIV early and enroll patients into care before they reach advanced clinical stages. This is fundamental to reducing early mortality and achieving SDG 3.3.
2. Develop Targeted Support Programs for Vulnerable Groups: In line with SDG 10, specific interventions should be designed for high-risk populations. This includes providing enhanced psychosocial and economic support for divorced individuals, especially women, to mitigate the social factors that contribute to poor health outcomes.
3. Enhance ART Adherence Support Systems: To support SDG 3.8, healthcare providers must reinforce patient education on the importance of adherence. This should be complemented by robust community- and facility-based support systems, including peer counseling and digital health reminders.
4. Integrate HIV Care with Broader Social Services: A holistic approach is needed that links HIV treatment with mental health services, social protection schemes, and gender-based support networks to address the complex drivers of mortality.

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

SDG 3: Good Health and Well-being

• The article’s primary focus is on the health outcomes of people living with HIV (PLHIV) in Ethiopia. It directly addresses the challenges of managing the HIV/AIDS epidemic by analyzing mortality rates, the effectiveness of antiretroviral therapy (ART), and factors influencing patient survival. The study’s aim to “identify factors associated with early mortality among ART users” is central to improving health and reducing deaths from communicable diseases, which is the core mission of SDG 3.

SDG 5: Gender Equality

• The article connects to SDG 5 by highlighting a significant gender-specific vulnerability. The study found that being a divorced woman is a major predictor of early mortality, stating, “divorced women had 6.34 (AHR: 6.34; 95% CI: 2.05, 19.65) times higher hazard of death.” The discussion explains this disparity is linked to social isolation, stigma, and loss of support systems, which are social and gender-related issues that impact health outcomes, thereby touching upon the goal of ending discrimination and ensuring well-being for all women.

SDG 10: Reduced Inequalities

• This goal is relevant as the article identifies specific high-risk groups that experience worse health outcomes, indicating inequality in the healthcare system’s effectiveness. The study points out that mortality is significantly higher for individuals in advanced WHO clinical stages, those with poor ART adherence, and divorced women. The recommendation to strengthen “ART programs with targeted interventions for high-risk groups” directly addresses the need to reduce these health inequalities.

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

SDG 3: Good Health and Well-being

• Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.

  The entire article is centered on the AIDS epidemic in Ethiopia. It discusses the expansion of ART to combat the disease, analyzes AIDS-related deaths, and references the UNAIDS 90-90-90 targets, which were a global strategy to end the AIDS epidemic. The study’s focus on reducing mortality among PLHIV is a direct contribution to achieving this target.

• Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

  The article mentions Ethiopia’s efforts to expand access to treatment, noting the “introduction of free ART services in 2005” and that “ART is available in more than 1,224 health facilities.” This demonstrates progress towards universal access to essential medicines (ART) and healthcare services for PLHIV. The discussion on treatment adherence also relates to the quality of healthcare services.

SDG 5: Gender Equality

• Target 5.1: End all forms of discrimination against all women and girls everywhere.

  The article’s finding that divorced women face a significantly higher risk of death points to underlying social discrimination and stigma. The discussion notes, “social isolation and stigma may discourage divorced women from accessing HIV care and treatment.” This highlights how discriminatory social norms create severe health disparities, making this target relevant to addressing the root causes of vulnerability for this specific group of women.

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

Indicators for SDG 3 Targets

• Mortality Rate/Incidence Density: The article provides a direct indicator of AIDS-related deaths, stating, “The mortality incidence density was 5.1 per 100 person-years.” It also reports an “overall mortality at the end of follow up period was 9.2%.” These figures are crucial for tracking progress in ending the AIDS epidemic under Target 3.3.
• UNAIDS 90-90-90 Targets: The article explicitly references these indicators to measure progress. It states that by 2017 in Ethiopia, “78% of the estimated people living with HIV (PLHIV) knew their status, of whom 71% were on treatment… the viral suppression rate (the third 90) was 88%.” These percentages are key performance indicators for Target 3.3.
• ART Coverage: As an indicator for universal health coverage (Target 3.8), the article provides data on the number of people accessing treatment. It notes that in 2017, “426,000 Ethiopians were receiving ART, despite an estimated 738,976 HIV-positive individuals in the country who need treatment.” This allows for the calculation of a treatment coverage rate.
• ART Adherence Rate: The study measures treatment adherence, an indicator of the quality and effectiveness of care. It found that “80.7% demonstrated good ART adherence during the follow-up period,” while poor and fair adherence were significant predictors of death. This is an implied indicator for the quality of health services under Target 3.8.

Indicators for SDG 5 Target

• Disaggregated Health Outcome Data: The statistic that “divorced women had 6.34… times higher hazard of death” serves as a powerful indicator of inequality and discrimination (Target 5.1). This disaggregated mortality data by marital status and gender reveals a specific vulnerability that social and health systems must address to ensure equitable outcomes for women.

4. Table of SDGs, Targets, and Indicators

Source: nature.com