Factors associated with mortality among people with advanced HIV disease in rural Uganda: a retrospective study

Background: Despite global efforts to improve HIV care, late identification and delayed antiretroviral therapy (ART) initiation continue to pose mortality risks among people living with HIV (PLHIV) with advanced HIV disease (AHD). This study investigated factors associated with mortality among PLHIV with AHD in rural North-Central Uganda from January 2018 to December 2021. Methods : We conducted a retrospective review of electronic medical records from 18 health facilities, and obtained data on patient demographics and clinical characteristics including baseline CD4 count, baseline ART regimen, current ART regimen, ART adherence, body mass index (BMI), tuberculosis (TB) status, TB preventive therapy (TPT) use, WHO clinical stage and viral load status. AHD was defined as CD4 cell count <200 cells/mm ³ . A Cox proportional hazard model was fitted to identify factors associated with mortality among individuals with AHD. Factors were summarized by adjusted hazard ratios (aHRs) with their 95% confidence intervals (CIs) and considered statistically significant at 5%. Results : 1,161 PLHIV with AHD records were analyzed, contributing 1,565.56 person-years (pya). Of these, 84 (7.2%) deaths were reported, equivalent to a mortality rate of 5.37 deaths per 100 pya (95% CI: 4.33–6.64). Factors significantly associated with mortality included age ≥50 years (aHR=4.16, 95% CI: 1.77–9.77,), never having had a viral load test (aHR=16.23, 95% CI: 7.44–35.39), viral load non-suppression (≥1000 copies/ml) (aHR=9.05, 95% CI: 3.37–24.29,), baseline CD4 count ≤50 (aHR=1.91, 95% CI: 1.08–3.39,), never having taken TB prophylaxis (aHR=3.51, 95% CI: 1.83–6.74) and WHO stage 3 or 4 (aHR=1.91, 95% CI: 1.12–3.27). Conclusion : Key predictors of mortality among patients with AHD were older age, absence of tuberculosis preventive therapy, CD4 ≤50 cells/mm³, viral load non-suppression, and WHO clinical stages 3–4. Interventions targeting early identification of AHD, routine viral load monitoring, ART optimization and adherence support, and universal TB preventive therapy—alongside close patient follow-up—are essential to reduce mortality and improve outcomes, contributing to HIV epidemic control by 2030.