Incidence and Predictors of Mortality Among Adults on Antiretroviral Therapy in Ethiopia: A Systematic Review and Meta-Analysis

Abstract

BACKGROUND: Despite the United Nations' plan to end Human Immunodeficiency Virus (HIV) as a public health concern by 2030, it remains a significant issue in low-income countries, including Ethiopia. Currently, there are no pooled estimates of mortality rate among adults on antiretroviral therapy in Ethiopia. This meta-analysis was conducted to fill this information gap, focusing on the incidence and predictors of mortality among adults receiving antiretroviral therapy in Ethiopia. METHODS: This systematic review followed the PRISMA guidelines, and relevant studies were obtained from the PubMed, CINAHL, Scopus, EMBASE, and Google Scholar databases. Data analysis for pooled estimates of incidence and predictors of mortality was conducted via STATA 17 software with the DerSimonian and Laird random-effects model. Heterogeneity was evaluated via Cochrane's Q-test and the I² statistic, and publication bias was assessed through funnel plots, Egger's test, and Trim-and-fill analysis. RESULTS: Of the 121,621 studies initially identified, only 31 met the rigorous inclusion criteria for the final meta-analysis, encompassing 24,504 participants in total. The pooled mortality rate among adults on antiretroviral therapy was 4 per 100 person-years (95% CI: 3-5, I² = 95.27%), based on 74,042.8 person-years of observation. Furthermore, advanced WHO clinical stage (pooled Adjusted Hazard Ratio(AHR) 1.68, 95% CI: 1.58-1.78), bedridden functional status (AHR 1.81, 95% CI: 1.67-1.95), anemia (AHR 1.89, 95% CI: 1.77-2.03), CD4 count below 50/mm³ (AHR 1.53, 95% CI: 1.42-1.65), fair or poor ART adherence (AHR 1.60, 95% CI: 1.45-1.75), and Tuberculosis co-infection (AHR 1.42, 95% CI: 1.32-1.53) were identified as predictors of mortality. CONCLUSION: The mortality rate observed in the current meta-analysis was clinically meaningful, indicating the need for strengthened efforts to reduce preventable deaths and achieve the 2030 targets. Moreover, advanced WHO clinical stage, bedridden functional status, anemia, CD4 count below 50/mm³, fair or poor ART adherence, and tuberculosis co-infection were identified as predictors of HIV-related mortality. This suggests that early HIV testing, timely initiation of treatment, and robust monitoring and evaluation of treatment should be prioritized to address the identified predictors.