Lessons learned from lives lost: mortality chart review of HIV-infected patients in Haiti
S. Sayana1, M. Laforest2, J. Chang2, C. Trout3, E. Robin4, H. Khanlou2
1Aids Healthcare Foundation, Internal Medicine, Los Angeles, United States, 2Aids Healthcare Foundation, Los Angeles, United States, 3Management Sciences for Health, PAP, Haiti, 4Aids Healthcare Foundation, PAP, Haiti
Background: Haiti has an adult-HIV-prevalence-rate of 2.2%. Mortality rates at 6 of our sites range from 5-15%. To investigate the high rate of mortality, we conducted an evaluation to assess the causes of death with the aim of recommending targeted-program-improvements.
Methods: This review was conducted between April to December 2009. We extracted data on causes of death, CD4-count at enrollment, time from enrollment to initiating anti-retrovirals (ART), patient's ART-regimens, subjective-objective data at the last visit before death and patient's clinical progress
Results: 150 charts were reviewed at 4 clinical-sites, from which, 101 were from patients who had died in the past 2-years and 49 were of living patients. From patients who had died, 68 female and 33 male charts were reviewed. The median CD4-count at enrollment was 146 cells/mm3 (range: 30-734), the average-time from enrollment to death was 8.5 months (range: 1-52), however, 40% of them died within 3-months. The actual causes of death were not documented in majority of the charts. Based on clinician review, factors contributing to death across all 4 sites, in order of frequency, were loss-to-follow-up due to lack of transport, delay in ART-initiation, late clinical presentation, HIV-TB-co-infection, 1st-line-failure and malnutrition. Each site had different leading factors that contributed to death. Based on these findings, efforts are being placed to emphasize HIV-testing; prioritize patients with low CD4-count and high-WHO-clinical-Stage; early recognition of treatment-failure; early use of 2nd-line-therapy; and appropriate initiation of ART in HIV-TB-co-infected-patients
Conclusions: : Identifying actual, site-specific causes of death are an evidence-based-method to find interventions that can be measurable and allows implementing direct corrective actions to yield better outcomes.
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