Factors influencing the survival of patients with advanced HIV disease in Guinea from 2015 to 2024

INTRODUCTION

Advanced HIV disease (AHD) remains associated with substantial mortality in routine care settings. We aimed to describe survival patterns and identify predictors of mortality among patients with AHD managed in Guinea, while also examining programmatic pathway variables relevant to continuity of care, including transfer into one of the nine specialized AHD sites, return after previous loss to follow-up, and visit intensity during follow-up.

METHODS

We conducted a retrospective cohort study using routine program data from patients with AHD enrolled in nine AHD care sites in Guinea between January 2015 and December 2024. Cohort entry was defined as the first documented AHD care visit at one of the nine study sites after AHD criteria were met. Follow-up was defined at the individual level from AHD cohort entry to death or censoring and was summarized in months and person-years. Median documented follow-up among analyzable individual follow-up intervals was summarized as median and interquartile range. Kaplan-Meier methods were used to describe survival patterns, and log-rank tests were used to compare curves. A principal multivariable Cox model was specified a priori using baseline predictors measured at cohort entry, and a secondary extended model additionally examined care-process variables accrued during follow-up. Programmatic pathway variables describing transfer into one of the nine study sites and return after previous loss to follow-up were examined descriptively and in exploratory analyses but were excluded from the principal prognostic model.

RESULTS

Among 24,090 individuals diagnosed with HIV during 2015-2024, 10,645 met the AHD definition and 1,289 died. Median documented follow-up was 2 months (IQR 1-5), corresponding to 2,529.8 person-years; the overall mortality incidence was 50.95 deaths per 100 person-years. In the principal multivariable model, mortality was higher among men (aHR 1.18, 95% CI 1.06-1.33), patients aged > 40 years (aHR 1.56, 95% CI 1.29-1.88), and those with WHO stage 3 (aHR 2.18, 95% CI 1.68-2.83) or stage 4 disease (aHR 4.20, 95% CI 3.19-5.52). Compared with new patients, transferred patients by ART initiation method had lower mortality (aHR 0.55, 95% CI 0.44-0.69). In the secondary extended model, confirmed TB or no documented TB screening at the last visit, fewer visits, and hospitalization during follow-up were associated with mortality in secondary exploratory care-process analyses. Exploratory pathway analyses showed lower observed hazards among patients transferred into the nine study sites and among those who returned after prior loss to follow-up; these findings were interpreted as referral, survivor selection, and re-engagement phenomena rather than as protective effects.

CONCLUSION

Mortality among patients with AHD in Guinea remained high and was concentrated in the earliest documented period after cohort entry. Male sex, older age, and advanced WHO stage were the most consistent baseline predictors of death. The analyses also highlight the operational importance of continuity-of-care markers such as visit intensity, inter-site transfer, and return after interruption of follow-up, all of which can signal episodes during which adherence may be compromised in patients already presenting with advanced disease. These findings support earlier diagnosis, stronger implementation of the AHD package of care, improved TB screening and management, closer early follow-up, and stronger coordination of transfer and re-engagement pathways.