Combination antiretroviral therapy in population affected by conflict: outcomes from large cohort in northern Uganda

OBJECTIVE: To measure the clinical and immunological outcomes of HIV positive adult patients receiving combination antiretroviral therapy in conflict affected northern Uganda. DESIGN: Prospective cohort study. SETTING: Gulu District, northern Uganda. PARTICIPANTS: 1625 adults (aged over 14 years) receiving combination antiretroviral therapy. MAIN OUTCOME MEASURES: PRIMARY OUTCOME: all cause mortality. SECONDARY OUTCOMES: impact of covariates (sex, age, CD4 count at start, adherence, tuberculosis at start, duration of treatment, and internally displaced person status) on mortality. RESULTS: Sixty nine (4.2%) patients died during follow-up. The mortality incidence rate was 3.48 (95% confidence interval 2.66 to 4.31) per 100 person years. Patients started treatment with a median CD4 count of 157 (interquartile range 90-220) cells/mul; most (1009; 63%) had World Health Organization stage 2 defined illness. Sixty two patients had pulmonary tuberculosis at the start of treatment. Of the 1521 patients with adherence data, 118 (7.8%) had adherence of less than 95% and 1403 (92.2%) had adherence of 95% or above. CONCLUSION: Patients receiving combination antiretroviral therapy in conflict affected northern Uganda had a mortality comparable to that of patients in peaceful, low income settings and better adherence than patients in higher income settings. These favourable findings highlight the need to expand access to combination antiretroviral therapy in populations affected by armed conflict.