Gender differences in HIV disease progression and treatment outcomes among HIV patients one year after starting antiretroviral treatment (ART) in Dar es Salaam, Tanzania

Fausta Mosha, Victor Muchunguzi, Mecey Matee, Raphael Z Sangeda, Jurgen Vercauteren, Peter Nsubuga, Eligius Lyamuya, Anne-Mieke Vandamme, Fausta Mosha, Victor Muchunguzi, Mecey Matee, Raphael Z Sangeda, Jurgen Vercauteren, Peter Nsubuga, Eligius Lyamuya, Anne-Mieke Vandamme

Abstract

Background: We investigated gender differences in treatment outcome during first line antiretroviral treatment (ART) in a hospital setting in Tanzania, assessing clinical, social demographic, virological and immunological factors.

Methods: We conducted a cohort study involving HIV infected patients scheduled to start ART and followed up to 1 year on ART. Structured questionnaires and patients file review were used to collect information and blood was collected for CD4 and viral load testing. Gender differences were assessed using Kruskal-Wallis test and chi-square test for continuous and categorical data respectively. Survival distributions for male and female patients were estimated using the Kaplan-Meier method and compared using Cox proportional hazards models.

Results: Of 234 patients recruited in this study, 70% were females. At baseline, women had significantly lower education level; lower monthly income, lower knowledge on ARV, less advanced HIV disease (33% women; 47% men started ART at WHO stage IV, p = 0.04), higher CD4 cell count (median 149 for women, 102 for men, p = 0.02) and higher BMI (p = 0.002). After 1 year of standard ART, a higher proportion of females survived although this was not significant, a significantly higher proportion of females had undetectable plasma viral load (69% women, 45% men, p = 0.003), however females ended at a comparable CD4 cell count (median CD4, 312 women; 321 men) signifying a worse CD4 cell increase (p = 0.05), even though they still had a higher BMI (p = 0.02). The unadjusted relative hazard for death for men compared to women was 1.94. After correcting for confounding factors, the Cox proportional hazards showed no significant difference in the survival rate (relative hazard 1.02).

Conclusion: We observed women were starting treatment at a less advanced disease stage, but they had a lower socioeconomical status. After one year, both men and women had similar clinical and immunological conditions. It is not clear why women lose their immunological advantage over men despite a better virological treatment response. We recommend continuous follow up of this and more cohorts of patients to better understand the underlying causes for these differences and whether this will translate also in longer term differences.

Figures

Figure 1
Figure 1
Kaplan-Meier Survival Curves on Time to Death, for 234 patients, Dar es Salaam.
Figure 2
Figure 2
Observed Opportunistic infection during one year of follow up, Dar es Salaam Tanzania.

References

    1. Palella F, Delaney K, Moorman A. Declining morbidity and mortality among patients with advanced Human Immunodeficiency Virus infections. N Engl J Med. 1998;338:853–860. doi: 10.1056/NEJM199803263381301.
    1. NACP, National AIDS Control Programme. Five Years of the National Care and Treatment Plan Tanzania (2003-2008): Success and Challenges. AIDS. 2009;35:856–4311.
    1. Oette M, Kroidl A, Göbels K. Predictors of short-term success of antiretroviral therapy in HIV infection. J Antimicrob Chemother. 2006;58:147–153. doi: 10.1093/jac/dkl189.
    1. National Guidelines for the Clinical Management of HIV and AIDS. National Aids Control Programme (NACP) Tanzania: Ministry of Health and Social Welfare Tanzania 2005 and 2009;
    1. World Health Organization. Disease Staging System for HIV Infection and Disease. 2006. .
    1. Stringer J, Zulu I, Levy J. Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. JAMA. 2006;296:782–793. doi: 10.1001/jama.296.7.782.
    1. Friedland G, Saltzman B, Vileno J. Survival differences in patients with AIDS. J Acquir Immune Defic Syndr. 1991;4(2):144–153.
    1. Nicastri E, Angeletti C, Palmisano L. Gender differences in clinical progression of HIV-1 infected individuals during long-term highly active antiretroviral therapy. AIDS. 2005;19:577–583. doi: 10.1097/01.aids.0000163934.22273.06.
    1. Cornell M, Schomaker M, Garone D. Gender differences in survival among adult patients starting antiretroviral therapy in south Africa: a multicentre cohort study. PLOS Medicine. 2012;9:e1001304. doi: 10.1371/journal.pmed.1001304.
    1. Maman D, Pujades-Rodriguez M, Subtil F. Gender differences in immune reconstitution: a multicentric cohort analysis in sub-Saharan Africa. PLoS One. 2012;7(2):e31078. doi: 10.1371/journal.pone.0031078.
    1. Druyts E, Dybul M, Kanters S. Male gender and the risk of mortality among individuals enrolled in antiretroviral treatment programs in Africa: a systematic review and meta-analysis. AIDS. 2012;26:000–000.
    1. Mocroft A, Gill M, Davidson W, Phillips N. Are there gender differences in starting protease inhibitors, HAART, and disease progression despite equal access to care? JAIDS J Acquir Immune Defic Syndr. 2000;24:475–482.
    1. Hawkins C, Chalamilla G, Okuma J. Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzania setting. AIDS. 2011;25:1189–1197. doi: 10.1097/QAD.0b013e3283471deb.
    1. Clark R, Blakley S, Rice J, Brandon W. Predictors of HIV disease progression in women. AIDS. 1994;9:43–50.
    1. Tanzania Commission for AIDS. Tanzania Health Indicator Survey (THIS) USA: Macro International Inc; 2008. (TACAIDS and Tanzania Bureau of Statistics, 2007/2008).
    1. Morlat P, Parneix P, Douard D. Women and HIV infection: a cohort study of 483 HIV-infected women in Bordeaux, France, 1985-1991. AIDS. 1992;6:1187–1193. doi: 10.1097/00002030-199210000-00020.
    1. Mugusi S, Mwita J, Francis J. Effect of Improved access to Antiretroviral Therapy on clinical characteristics of patients enrolled in the HIV care and treatment clinic, at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania. BMC Public Health. 2010;291(10):1471–2458.
    1. Alibhai A, Kipp W, Saunders D. Gender-related mortality for HIV-infected patients on highly active antiretroviral therapy (HAART) in rural Uganda. International J Women’s Health. 2010;2:45–52.
    1. Wood E, Montaner J, Yip B. Adherence and plasma HIV RNA responses to Highly active antiretroviral therapy among HIV-1 infected injection drug users. Cmaj. 2003;169(7):656–661.
    1. Theresa W, Stefan G, Nicholas J. Episodic homelessness and health care utilization in a prospective cohort of HIV-infected persons with alcohol problems. BMC Health Serv Res. 2006;6:19. doi: 10.1186/1472-6963-6-19.
    1. Bagasra O, Bachman S. Increased human immunodeficiency virus type 1 replication in human peripheral blood mononuclear cells induced by ethanol, Potential immunopathogenic mechanisms. J Infect Dis. 1996;173(3):550–558. doi: 10.1093/infdis/173.3.550.
    1. Gandhi M, Bacchetti P, Miotti P. Does patient Sex affect human immunodeficiency virus levels? Clin Infect Dis. 2002;35:313–322. doi: 10.1086/341249.

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