Discussion
The main goal of this study was to estimate the mortality rate of PLHIV after second-line ART and to identify its effectors in rural China. The overall mortality rate of was 1.88/100 person-years with a lowest level compared with the study on the survival of PLHIV after ART don’ care first or second-line in Guizhou in China, where the mortality rate was with 8.53/100 person-years [20], or a study in and Henan in China, where the mortality rate was with 3.9/100 person-years [21], which it maybe the second-line ART had good efficacy. Another study conducted in African and Asian in 2010 reported the mortality rate was 4.42/100 person-years after patients switch to second-line ART [22], higher than this study. According to the global HIV statistics fact sheet reported by WHO, the mortality rate of PLHIV was decline sharply [1]. The different results among the studies might be due to difference in characteristics sample, in length of study or in the study period.
The effect of gender on survival has often been the focused, but the result had varied in the literature. Here, we find a significant difference between women and men as most studies report that women had a lower risk of death than men [23, 24]. The results of studies vary on the association of marriage with survival. Here, we find that single/window individuals are a risk factor for failure in second-line ART, which is consistent with some research findings. For example, A multivariable analysis showed that single status (unmarried or divorced) was a risk factors for PLHIV with second-line ART [25]. Older age was a higher risk of death, we report that the HR of death among PLHIV older than 50 years was 2.56 times that of those under 40, patients with 40-50 years old was not show higher HR of death compared with those under 40. Some studies have reported that older PLHIV had more comorbidities and be significantly associated with second-line ART failure [26]. Here we show that level of education was significantly associated with mortality. Compared to patients with an education level <6 years, patients with an education level >6 years have a 0.8-fold higher risk of death.
A lower CD4+ T cell count at switch to second-line was independent risk factor on time to death, which accordance with many studies. The HR of death among PLHIV with CD4+ cell count lower than 200 cells/µl was 1.89 times that of higher than 500 cells/µl. Patients with lower CD4+ cell count were found to be significantly associated with second-line ART failure and have higher probability of developing different opportunistic infections [27], all those more were apt to cause death. Anemia has been documented as a risk factor for morbidity and mortality in these patients, even if the CD4+ cell count and viral load are controlled [28-30]. However, in our study the anemia had not affect the mortality of PLHIV with second-line ART. AST/ALT≥50 u/L, which was defined as liver injury [18], was the risk factor of death of PLHIV. In this study, we find that participants with liver injury have a 1.58-fold higher risk of death compared with these participants who without liver injury. Some study show that liver injury may induce cirrhosis and hepatocellular carcinoma and thereby increase the risk of death of PLHIV [31, 32].
Here we show that the mortality rate of PLHIV in the CM group was 1.48/100 person-years (HR, 0.75; 95%CI, 0.52–0.96) compared with 1.98/100 person-years of participants who were not treated with CM. The result suggested that CM combined with second-line ART could better increased the survival and lengthened the lifetime of PLHIV. In Henan, CM has been used to treat HIV/AIDS for decade, many effects of CM on HIV/AIDS have been shown. For example, CM reduces plasma HIV viral loads, increases CD4+ T cell counts, promotes immune reconstitution, diminishes signs and symptoms, improves health-related quality of life, and reduces the adverse effects of antiretroviral drugs [33-36].