Background: Timely initiation of ART, adherence support, proper management of virologic failure are important strategies for reaching the ambitious 90-90-90 goals in Ukraine and globally. Key national stakeholders and international donors set ambitious fast track goals to increase the number of patients from 88,270 on 01/01/2018 to 140,000 by the end of 2018. This study was commenced to obtain reliable data on key determinants of mortality that need to be tackled to improve treatment effectiveness and inform program planning.
Methods: Data from medical charts of all patients who started ART in 2010-2016 in 18 out of 27 regions of Ukraine were entered into an electronic medical record system. After verification of data quality, depersonalized datasets linked by unique patient code were extracted at each facility and merged for analysis.
This analysis focused on the effect of clinical variables (mode of HIV transmission, clinical stage, CD4, VL, TB, HCV, injecting drug use [IDU]) on probability of death. The entire dataset, excluding children younger than 15 at diagnosis, was analyzed using Cox proportional hazard models.
Results: The cohort included 33,589 patients; median age at ART initiation was 36 years, 47.9% were females. 2,418 (7.2%) patients died during 90,486 person-years (PY) of observation, resulting into 2.67/100PY death rate (95% CI: 2.57-2.78).
In the multivariable Cox regression model, higher probability of death was associated with male gender (aHR=1.42, 95% CI: 1.26-1.59), history of IDU (aHR=1.17, 95% CI: 1.04-1.31) and current IDU (aHR=2.03, 95% CI: 1.70-2.42, compared to unconfirmed IDU status), and a positive TB clinical test (aHR=1.95, 95% CI: 1.69-2.24, compared to unknown TB status). Protective factors were higher CD4 count at ART initiation (aHR=0.20, 95% CI: 0.16-0.24, for >500 compared to < 200), last viral load result < 200cp/ml (aHR=0.28, 95% CI:0.25-0.31).
HCV negative status was a significant predictor of survival in univariable analysis (HR=0.59, 95% CI: 0.53-0.65), but became not significant in the multivariable model.
Conclusions: Survival of patients on ART in Ukraine remains suboptimal. Higher mortality in advanced stages of disease highlights the importance of implementation of test-and-start strategy. Adequate management of comorbidities, especially drug dependence, TB and HCV is crucial for improved survival.