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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Int J Infect Dis. Author manuscript; available in PMC May 2, 2008.
Published in final edited form as:
PMCID: PMC2365735
NIHMSID: NIHMS46218

HIV morbidity and mortality in Jamaica: analysis of national surveillance data, 1993–2005

Summary

Objectives

Pre-antiretroviral therapy (ART) HIV-related survival and timing of HIV identification have not been reported from the Caribbean. Using Jamaican national surveillance data, we estimated overall, AIDS-free, and AIDS survival, identified factors influencing HIV-related mortality, and examined factors associated with late HIV/AIDS identification.

Methods

The Jamaican HIV/AIDS tracking system (HATS) national surveillance data included timing of first positive HIV test, stage at identification, date of AIDS diagnosis, and death. We estimated overall and AIDS-free survival by initial stage, using a proportional hazard model to identify factors associated with worse survival, and logistic regression to examine factors related to later case identification.

Results

Of 10 674 reported HIV cases, 48% were asymptomatic, 14% symptomatic, and 38% first reported with AIDS. Five-year AIDS-free survival was 77% for asymptomatic persons and 63% for symptomatic. Median survival after AIDS diagnosis was 1.02 years. Age, number of opportunistic diseases, and initial stage were strongly associated with mortality. Older age, drug use, and sex with a commercial sex worker were associated with later identification.

Conclusions

In the pre-ART era, over one-third of HIV-infected persons in Jamaica were first identified with advanced disease. This highlights the need for earlier diagnosis as ART programs roll out in the Caribbean.

Keywords: HIV, AIDS, Morbidity, Mortality, Jamaica, Caribbean

Introduction

An estimated 250 000 people are living with HIV in the Caribbean, and more than 19 000 people died of AIDS in this region in 2006 alone.1 Jamaica is the third largest Caribbean island (estimated population 2 760 000) with a documented HIV prevalence of 1.5%.2,3 The Jamaican Ministry of Health, through its National HIV/STD Prevention and Control Program, has carefully documented countrywide trends in the HIV/AIDS epidemic, including incidence of AIDS cases, rate of HIV infection, HIV prevalence, and mode of HIV transmission.46 While data from the early years of the epidemic in Jamaica showed an AIDS case rate that doubled every two years between 1987 and 1993,4 the yearly increase in AIDS incidence has subsequently slowed, which has been attributed to the scale-up of the National HIV/STD Prevention and Control Program.5 The HIV/AIDS tracking system (HATS) national surveillance data are a rich resource for studying HIV epidemic-related information. Though the HIV/AIDS epidemic in Jamaica has been well described, there are few data documenting HIV-related survival, the prevalence of HIV morbidities, and factors associated with worse survival and later case identification.35,7

Understanding HIV-related survival during the pre-antiretroviral therapy (ART) era is crucial for developing and evaluating the success of the growing ART program in Jamaica. As access to ARTwas limited in Jamaica prior to 2005, there were few persons in the HATS data on ART. We analyzed the HATS database to assess: (1) survival in HIV-infected persons in Jamaica and factors influencing HIV-related mortality, (2) prevalence of HIV-related morbidities, and (3) factors associated with later case identification. These data can provide insight for planning and implementing effective prevention and care interventions including ART programs in Jamaica and, more widely, in the Caribbean region.

Methods

Data source and data elements

The Jamaican national HATS data collected from 1993 to 2005 were used for this analysis. HATS data collection was conducted through provider-initiated reporting as well as through active hospital surveillance using a standardized instrument. The date and results of HIV tests, clinical data including documentation of HIV-related morbidity, and disease stage (asymptomatic HIV, symptomatic HIV, AIDS, and death) were captured. Standard case definitions for HIV morbidities were used. The data also included information on demographics including age, sex, and risk factors for HIV infection. Risk factors included drug use (cocaine or injection drug use), sex with a commercial sex worker, history of or current sexually transmitted disease, and history of blood transfusion. The HATS database team has several established measures to maintain the confidentiality and security of the data, including strictly confidential name-based reporting, limited size of the surveillance team, restricted access to the surveillance database, and a code-based version of the database used for research purposes.

To adjust for secular trends in HIV-related survival, we divided the surveillance data into three eras according to the date of case identification (January 1, 1993 to December 31, 1996, January 1, 1997 to December 31, 2000, and January 1, 2001 to June 1, 2005). To ensure completeness of the data, this analysis was restricted to persons who were diagnosed after 1993. Persons with inconsistent data were excluded to maximize completeness.

Statistical analysis

In the survival time analysis, we distinguished three types of survival: overall survival for HIV-infected persons, AIDS-free survival, and survival of persons living with AIDS (PLWA). To estimate overall survival, the follow-up time for the analysis was determined from the time of the first positive HIV test to the date of death for those who died or to the end of the follow-up period (June 1, 2005) for those who remained alive. AIDS-free survival was estimated for those diagnosed at earlier stages of disease (asymptomatic HIV and symptomatic HIV) with follow-up time defined from the date of the first positive HIV test to the date of AIDS diagnosis for those who developed AIDS or to the end of the follow-up period for those whose date of AIDS diagnosis was missing. We also estimated survival of PLWA, defining follow-up time from the date of the first diagnosis of AIDS to the date of death or the end of the follow-up period for those who did not have a recorded date of death.

We used the Kaplan–Meier method to estimate overall, AIDS-free, and PLWA survival. We built proportional hazard models to perform a multivariate analysis to identify factors associated with worse survival. We also used logistic regression models to examine factors related to later HIV identification. For the purpose of this analysis, risk factors were divided into six groups: (1) drug use (cocaine or injection drug use), (2) sex with a commercial sex worker, (3) history of or current sexually transmitted disease, (4) blood transfusion, (5) pregnancy, and (6) other risks. All analyses were performed using SAS 9.1 (SAS Institute, Cary, North Carolina, USA); two-sided p-values <0.05 were used to define statistical significance.

Results

Sample description

A total of 10 674 HIV-infected adults reported to the Jamaican national surveillance program between January 1, 1993 and June 1, 2005 met the inclusion criteria for the analysis (Table 1). The majority of reported HIV cases (87%) were at least 25 years of age, and 53% were male. Five thousand one hundred fifty-four people (48%) were identified with asymptomatic HIV, 1480 (14%) were identified with symptomatic HIV, and 4040 (38%) were first reported with an AIDS diagnosis. Forty-eight percent of people had at least one defined symptom complex or opportunistic disease throughout the course of follow-up and 38% were observed to have two or more symptom complexes during follow-up. The number of people reported with HIV also increased over time, (1751, 3531, and 5392 cases of HIV reported over the three time periods), with the proportion of reported cases with AIDS greatest in the earliest time period (Table 2). The proportion of patients reported earlier in the course of disease was greater in the more recent time periods (52% and 50% reported with asymptomatic HIV in the second and third time periods, respectively). The cumulative incidence of progression to AIDS over the 11.5 years was 24% (1616 AIDS cases/6634 persons) or 5.7 cases/100 person-years (PY). Progression to AIDS was lower for those who presented with asymptomatic HIV (5.0 cases/100 PY) compared to those who presented with symptomatic HIV (8.0 cases/100 PY).

Table 1
Characteristics of persons in the Jamaican HIV/AIDS tracking system (HATS) database: 1993–2005
Table 2
Factors associated with late case identification in the Jamaican HIV/AIDS tracking system (HATS) database: 1993–2005

Survival

Three thousand three hundred sixty-eight HIV-infected persons died during the follow-up period (a total of 38 120 PY), yielding a mortality rate of 8.8 deaths/100 PY. Death rates were higher with increasing age, later stage of presentation, greater number of symptom complexes or opportunistic diseases, and unknown risk factors (Table 1). Mortality rates were significantly higher for those identified at a later stage of HIV disease (23.3 deaths/100 PY for those with AIDS at identification, 5.6 deaths/100 PY for persons with symptomatic HIV at the time of identification, and 3.3 deaths/100 PY for those identified with asymptomatic HIV). Among persons presenting with asymptomatic HIV, one- and five-year survival rates were 97% and 85%, compared to 91% and 72% for persons initially presenting with symptomatic HIV and 56% and 40% for persons initially presenting with AIDS. Median survival after an AIDS diagnosis was 1.02 years (Figure 1).

Figure 1
Survival of HIV-infected persons in Jamaica by initial stage at time of report to HIV/AIDS tracking system (HATS) database.

We also estimated AIDS-free survival for persons initially presenting at earlier stages, prior to development of AIDS. One- and five-year AIDS-free survival for persons diagnosed with asymptomatic HIV were 92% and 77%, compared to 81% and 63% for persons diagnosed with symptomatic HIV.

Factors associated with increased mortality

Multivariate analysis revealed that after simultaneous adjustment for age at first diagnosis, gender, calendar date of diagnosis, number of symptom complexes or opportunistic diseases associated with HIV, and risk factors for HIV, the initial stage of presentation was strongly associated with mortality. Persons diagnosed earlier in the course of disease (asymptomatic HIV and symptomatic HIV) had a lower hazard of death (0.32 and 0.49) compared to persons first identified with AIDS. Age, a greater number of opportunistic diseases and symptom complexes, and date of diagnosis were also strongly associated with increased mortality (Table 1).

Factors associated with later presentation to care

After adjusting for gender, calendar date of diagnosis, number of opportunistic diseases at the time of diagnosis, initial stage of presentation, and risk factors for HIV, persons over age 40 were identified later in the course of disease compared to those in younger age groups (Table 2). History of drug use, sex with a commercial sex worker, and unknown risk factors were also associated with later presentation to care.

Prevalence of symptom complexes and opportunistic diseases at diagnosis

Males had a significantly higher overall prevalence of symptom complexes or opportunistic diseases than females (Figure 2). The most prevalent symptom complexes observed were wasting with weight loss greater than 10% of body weight (39%), chronic cough greater than 1 month (30%), oral candidiasis (26%), and shortness of breath (25%).

Figure 2
Overall prevalence of symptom complexes and opportunistic diseases in the HIV/AIDS tracking system (HATS) database, stratified by gender. SOB, shortness of breath; Lymph, lymphadenopathy; Gen Derm, generalized dermatitis; CNS, central nervous system involvement; ...

Discussion

We analyzed Jamaican HIV/AIDS surveillance data for the period from 1993 to 2005 to understand trends in survival and presentation to care in the pre-ARTera in Jamaica. We found that over one-third of HIV-infected persons in Jamaica were identified late (with an AIDS diagnosis) and that overall progression to AIDS was 5.7/100 PY. This rate of progression was higher in symptomatic persons than in asymptomatic persons. Mortality rates were also higher in symptomatic persons than in asymptomatic persons, which is consistent with data from other countries.8 One- and five-year survival rates were 97% and 85% for asymptomatic persons, 91% and 72% for persons with symptomatic HIV, and 56% and 40% for those with AIDS.

The distribution of stage of disease at the time of presentation is consistent with prior work in Jamaica by Vickers et al., with most persons presenting with asymptomatic HIV.7 The spectrum of morbidities that we describe is also consistent with the limited literature on HIV disease in Jamaica, with the most common symptom complexes and opportunistic diseases including HIV wasting, cough, oral candidiasis, and shortness of breath.7 While lymphadenopathy was the most common presentation in the study by Vickers et al., wasting and cough were the most prevalent symptoms seen in the HATS dataset. Complete data are still lacking concerning the etiology of common clinical presentations of HIV disease and the relative frequency of opportunistic diseases in the Caribbean region. Aside from the work done in Jamaica, there are few reports of HIV/AIDS outcomes in the Caribbean region, with the best data available from Barbados and Haiti. Morbidity at presentation in a clinical cohort from Barbados showed that the most commonly seen HIV-related diseases at presentation in those presenting with symptomatic HIV were ‘other’ diseases, followed by oral candidiasis and generalized lymphadenopathy.9 The most common cause of death in the Barbados cohort was opportunistic infections, a result that supports our finding of higher mortality rates in symptomatic persons. Though there are numerous reports on HIV-related morbidity and mortality from Haiti, the spectrum of disease there differs from that seen in the English-speaking Caribbean.1012 Deschamps et al. reported tuberculosis to be the most common HIV-related illness at presentation in Haiti, followed by chronic diarrhea and prurigo.11 Comparisons with specific morbidities that have been reported in other resource-limited countries, including Côte d’Ivoire, Uganda, South Africa, and India, are difficult, since the HATS dataset described a combination of clinically observed symptom complexes and diagnosed opportunistic diseases.8,1315 However, the most common opportunistic disease described in the HATS was oral candidiasis, which is consistent with data from other countries.15 Whether the cough and shortness of breath reported in the HATS reflect cases of Pneumocystis jirovecii pneumonia, as in other settings, cannot be fully determined because of incomplete data on microbiologic diagnoses.

Factors associated with later presentation to care included older age, history of drug use, sex with a commercial sex worker, and unknown risks. While studies in other Caribbean countries have not reported the predictors of later presentation to care, the importance of timely presentation for HIV care is widely recognized, and reports on timing of presentation for care have been made from Barbados and Haiti.16,17 Kumar et al. reported that nearly three-quarters of a clinical cohort in Barbados was diagnosed with HIV infection for the first time during terminal hospitalization.16 Ivers et al. reported encouraging results from Haiti, with persons presenting to a rural primary care clinic with a median CD4 cell count of 321/μl and an overall low rate of missed opportunities for HIV diagnosis observed.17 While the current study is the first to report specific predictors of later presentation for care in the Caribbean, these predictors have been examined in developed settings. In two studies from Australia, older age was consistently a predictor of later presentation to care, as was seen in the HATS.18,19 The other predictors of later presentation to care reported in the studies from Australia, as well as those reported in one study from the USA, were different than those seen in Jamaica, which may be due to different person characteristics in the populations studied.1820 These discrepancies highlight the importance of these setting-specific results from Jamaica for the planning of national HIV/AIDS policy and response.

Overall mortality in this study was lower than in other resource-limited countries.8,11,21 In Barbados, an overall HIV-specific death rate of 26.8/100 000 adults has been reported, a rate that is not directly comparable to our results as the authors did not report person follow-up time.16 In a report from a longitudinal cohort study in Haiti, investigators found a median time to AIDS of 5.2 years and a median time to death of 7.4 years, estimates substantially shorter than we found in the current analysis from Jamaica (greater than 50% of those with asymptomatic HIV and those with symptomatic HIV remained AIDS-free at the end of the follow-up period in the current analysis).11 A review of the natural history of HIV disease in Africa found mortality rates ranging from 9.3/100 PY to 15.7/100 PY in different African settings.21 In an additional cohort in West Africa, overall mortality was reported as 19.8/100 PY, more than twice the rate observed in the HATS.8 A possible explanation for these discrepancies, in addition to the differing spectrum of disease between settings, is the difference in data type; a greater percentage of persons may be lost to follow-up in a surveillance dataset compared to a longitudinal cohort, leading to an underreporting of death in the surveillance data.22,23 Significant predictors of mortality included age, date of diagnosis, number of opportunistic diseases and symptom complexes associated with HIV, and initial stage of presentation. These findings are consistent with other studies from Asia and Africa where age, gender, and stage of disease have all been found to be predictors of mortality.2428 There have been no previously published studies on predictors of mortality in the Caribbean.

The incidence and prevalence of HIV in Jamaica have been reported;3 however, no studies to date have documented HIV-related survival, and the factors associated with worse survival and later case identification. This is the first study to utilize the HATS database to assess survival and to identify factors influencing survival in HIV-infected persons in Jamaica prior to the introduction of wide access to ART through the national program. The presentation of persons with multiple symptom complexes and with a clinical diagnosis of AIDS suggests the need for better screening programs in the region to help identify HIV-infected persons earlier in the course of disease; a preliminary report on HIV testing in Jamaica reported only 38% of sexually experienced persons had had an HIV test.29 Further, there are reports of high levels of stigma towards HIV-infected persons in Jamaica, which may deter individuals from seeking HIV testing.30 Of the risk behaviors reported, ‘unknown’ risk behavior was the greatest predictor of mortality and late presentation. This emphasizes the need for better reporting mechanisms of risk behaviors within this population. History of drug use and sex with a commercial sex worker were also found to be predictors of later presentation to care and indicate the need for better targeting of prevention and screening programs to these high-risk populations in Jamaica who may be less likely to access HIV testing and care until they are symptomatic or have developed AIDS.

There are several limitations to this study. Although the HATS dataset is the only dataset in Jamaica with data on HIV-related morbidity and mortality, there is substantial loss to follow-up in the dataset, which may lead to underestimation of mortality, particularly over time.22 Furthermore, staging of disease was done as asymptomatic HIV, symptomatic HIV, and AIDS for surveillance purposes, and not by WHO staging criteria, which were designed to measure clinical progression. The dataset also lacks CD4 cell count measurements because they were not available in Jamaica during the period of data collection that is examined in this study.

In summary, these data show a trend of late case identification of HIV-infected individuals in Jamaica. This study demonstrates the value of collecting and analyzing national surveillance data, even those without specific clinical markers such as CD4 cell counts, for guiding the development of national prevention and treatment programs. Further, the collected data may be used as a benchmark to measure the success of HIV treatment programs. This model can and should be applied to other settings to identify areas in which interventions are most required in each setting. In Jamaica, the data highlight the need for earlier HIV diagnosis and stronger efforts to scale up antiretroviral treatment programs.

Acknowledgments

Funding support was received from the National Institute of Allergy and Infectious Diseases (NIAID R01 AI058736, P30 AI060354, K25 AI50436, and K24 AI062476). The authors also gratefully acknowledge the contributions of the entire Cost-Effectiveness of Preventing AIDS Complications (CEPAC) team.

Footnotes

Conflict of interest: No conflict of interest to declare.

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