The use of antiretroviral therapy has been associated with prolonged survival among people living with HIV/AIDS in the world [1
]. The median survival time after ART initiation during the study period was found to be 24 months in this population. This was comparable to what was reported in a study done in Ethiopia by Andinet and Sebastian [13
]. However, median survival time in this population was lower than that reported in other studies in the country [14
] and that done in Uganda [15
]. On the other hand, patients in this study survived longer than those reported in studies conducted in South Africa [16
]. These variations indicate that although ART increases survival, it is not the only determinant of survival among people living with HIV/AIDS but could depend on the characteristics of the patients, adherence, and quality of service provision [6
Mortality in this study was found to be 4.3/100 person-years at risk with more death occurring during the first five months following ART initiation. These findings are similar to what has been reported elsewhere [9
]. High death rate in the beginning of ART use has been associated with immune reconstitution inflammatory syndrome especially for patients staring treatment with advanced diseases (WHO stage 4) [10
]. A study in Ethiopia established that the high mortality during the first months of treatment was strongly associated with advanced clinical stage and weight loss [10
]. Additionally, studies in Tanzania and South Africa observed that there were more deaths occurring within three months after ART start and were strongly associated with anaemia, thrombocytopenia, and severe malnutrition [14
A large proportion (68.9%) of patients in this population was found to start ART with disease stage 3/4 with more than one-third (36.8%) starting with advanced WHO stage 4 disease. This proportion was significantly larger as compared to the national average of 35% for WHO stage 3/4 disease [1
]. However, the median CD4 cells of 156
at the start of ART were in the range of what has recently been reported in East Africa (154
] which was also comparable to contemporaneous estimates of 187
in the United States, 159
in Brazil, and 157
in China [23
]. The large proportion of advanced disease patients in this study could partly be explained by the service provision nature of distantly located districts and regions in country. Only 5 out of 19 health facilities in this region offered ART services, and this could somewhat limit easy access especially for those residing far from the facilities. Most people from larger cities such as Dar Es Salaam where many facilities can offer HIV testing and ART could timely access health education, HIV testing, and ART as compared to region with limited resources.
This study also showed males to have higher mortality rate than females. This finding was similar to other studies in Africa which showed mortality rate to be higher in males than in females [7
]. Late reporting of men to care and treatment clinics and poor adherence to treatment are among the reasons identified by various studies [23
]. Studies suggested that female patients tend to know their HIV status and start antiretroviral therapy early with better CD4 cell count compared to males. This has been explained to be due to the linkage between prevention of mother-to-child transmission (PMTCT) and care and treatment clinics [24
]. Most patients especially men would go for HIV testing after experiencing HIV/AIDS-related symptoms. As found in this study, a study involving three east Africa, countries has indicated that males start ART with advanced disease as compared to female [22
]. The study also indicated that the advanced disease profile of men as compared to women at the starting ART could not fully be explained by the public health services giving women a PMTCT testing advantage. This was because men were 50% more likely to assess ART with advanced disease as compared to women without any history of PMTCT. Further studies were suggested to examine causal reason for late reporting among men [22
Patients residing in urban areas had higher death rates as compared to those from rural communities. Traditionally, rural communities are more supportive, extended with social cohesion than urban communities. People living with HIV/AIDS could benefit from these supports which may include drug adherence support, nutrition support, and other sick role benefit that may be instrumental in survival. Moreover, relatively fewer number of HIV infected patients in rural areas could make it easy for the health system to support them adequately and effectively with the help of community HIV/AIDS support staff.
Lower body weight (cachexia or wasting syndrome) and lower CD4 count are proxy measures of advanced disease stage. Patients stating ART with advanced disease stage as defined by WHO stage 4 are associated with increased risk of immune reconstruction syndrome and death. In this study we found that patients with advanced disease WHO stage 4 mostly characterised by lower body weight (weight below 45
kg) and lower CD4 count (less than 50
) were associated with higher rate of death. Low body weight has also been associated with malnutrition hence poor immunity among HIV infected-individuals. These findings were consistent with that of a study done in Ethiopia [13
], where patients who were given antiretroviral therapy with low body weight had higher mortality. Another study in Uganda reported that CD4 count above 200
was associated with better survival among HIV-infected patients [15
]. These findings underpin the importance of promoting voluntary and HIV testing to facilitate early disease diagnosis and early ART start hence relatively low associated mortality.
Many countries including Tanzania have started to provide nutritional support to people living with HIV who are on ART. This is now part of the HIV care and treatment policy but its implementation has not been effective as most clinics are not offering this service. Lack of nutritional support and late HIV diagnosis have been a drawback to the anticipated positive effects of ART scale-up in poor countries.
The findings of this study should be interpreted in light of the following limitations; our analysis was based on secondary data that were not collected for research purposes. Important predictors of survival such as drug adherence, economic status, and drug resistance were missing.