A Research Report Submitted to the School of Public Health, University of the Witwatersrand, Johannesburg, in Partial Fulfilment of the Requirements for the Degree of Master of Science in Medicine in the Field of Epidemiology and Biostatistics: March 25, 2013 / Background: More than 33 million people are estimated to be living with HIV worldwide. Sub-Saharan Africa bears a disproportionate share of the global HIV burden. An estimated 15 million people living with HIV in low and middle income countries were in need of (HAART) in December 2009. HAART services require advanced laboratory technologies to monitor disease progression and therapeutic response, which are scarce in developing countries. Several simple and widely available markers have been proposed for use in low income countries including total lymphocyte count (TLC), haemoglobin and body mass index. Methodology: This study is a secondary data analysis of prospectively collected cohort data from HIV positive adults. The study measured the effect of exposure variables of haemoglobin (Hb) and body mass index (BMI). All cause mortality was the outcome of interest. Crude estimates of mortality were made with Kaplan-Meier mortality curves. Cox proportional hazards models were used to estimate adjusted hazard ratios. Exposure status was considered at initiation period. Outcomes were measured from two weeks post initiation of treatment to a maximum of two years of follow-up period. A composite score was developed to estimate the overall risk of mortality. Results: A total of 11,884 patients who satisfied the inclusion criteria were included in the analysis. A total of 1,305 deaths were observed during the follow-up period, representing 10.2% of the cohort at baseline. Most of the deaths were observed during the first four months of follow-up period. Patients with moderated to severe anaemia experienced 2.6 (HR = 2.6, 95% CI 1.8 - 3.6) times greater hazard of mortality adjusted for possible confounders. Patients with very iv low BMI experienced twice (HR=2.0, 95% CI 1.6, -2.5) greater hazard of mortality adjusted for a list of predictors. Race, age at initiation, employment status, smoking, alcohol consumption, baseline TB and baseline WHO stage did not show significant effect in the multivariate cox regression model. A composite score was developed to estimate the overall risk of mortality in patients based on measurements of baseline BMI and haemoglobin. Cox regression model adjusted for CD4 cell count shows high risk patients experienced 4.7 (HR = 4.7, 95% CI 2.9 – 7.6) times greater hazard of mortality compared to patients in the low risk group. Patients in the medium risk group experienced 3.4 (HR = 2.6, 95% CI 2.6 – 4.4) times greater hazard of mortality as opposed to patients in the low risk group. Conclusion: Haemoglobin and body mass index provide excellent prognostic information independent of CD4 cell count in HIV positive patients newly initiated on HAART. They can be used to reliably predict mortality. Combining measurements of haemoglobin and BMI through composite scoring improves their predictive ability. They can have good clinical application in rural and remote facilities to screen patients for clinical and diagnostic services.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Masters of Medicine. Johannesburg 2019 / Background: The high level of co-morbid TB/HIV cases with severe organ failure on presentation in South Africa, results in an increased number of ICU admissions often with a poor prognosis at presentation. In this study, the aim was to identify patients admitted with HIV/TB co-infection and calculate the APACHE II scores and SOFA scores for each patient. Predicted percentage mortality was compared with actual mortality. Predictors of mortality were further identified, as well as the benefit of initiating ARV treatment in patients who are ARV naive upon admission to ICU. Methods: A retrospective audit of consecutive cases over a 24 month period was completed. Patient demographics; CD 4 count; ARV treatment status; ICU and 30 day mortality; the APACHE II Score; SOFA scores and correlating predicted percentage mortality were documented. The survival of patients was assessed using Kaplan Meier survival curves, and a univariate analysis was performed to identify risk factors for mortality. Calculated predicted mortality was compared with actual mortality to validate each scoring system and infer which was the better tool. Results: Of 75 patients admitted with pulmonary (43 cases) or extra-pulmonary (32 cases) TB, 23 died in the ICU (mortality 30,7%), and a further 10 died in the first 30 days of hospitalisation (30 day mortality 44%). A survival analysis established ARV treatment and CD 4 counts greater than 50 cells/mm3 were associated with a higher survival rate at any point of the analysis. In the entire study period, only 2 patients were initiated on ARV therapy during their ICU stay, 1 survived to discharge and 1 died in ICU. The APACHE II Predicted Mortality was within the 95% Confidence Intervals for all groups while the SOFA score was outside the upper bound limit of the 95% confidence intervals of actual mortality for those patients taking ARV treatment (52%, 95% CI 43,1% - 59,5% vs actual mortality 30%, 95% CI 17,7% - 46,1%), those with a CD 4 count of more than 50 (53,5% 95% CI 45,4% - 60,6% vs actual mortality 34%, 95% CI 22,1% - 48,4%) and female patients (51,2%, 95% CI 41,6% - 58,1% vs actual mortality 35,1%, 95% CI 21,4% - 50,4%). Conclusion: The study found that both the APACHE II and SOFA scoring systems were both statistically significant in prognosticating mortality in the study population. The APACHE II scoring system however showed a slightly improved prognostication in specific cohorts who had improved survival. It was also confirmed that patients with a CD 4 count of more than 50 cells/mm3, and those on ARV therapy had a statistically significant improved mortality. Further studies reviewing survival benefit of ARV initiation in ICU are warranted. ACKNOWLEDGEMENTS Supervisor: Prof GA Richards Co-Supervisor: Dr SHH Mohamadali Statistician: Mr MH Zondi Assistant - Data Collection: Ms S Madanlall / E.K. 2019