Gender differences in mortality and loss to follow-up among HIV-positive patients on antiretroviral therapy in Tigray, Ethiopia


  • Raffaella Bucciardini Istituto Superiore di Sanità
  • Paola Tatarelli
  • Esayas Haregot Hilawe
  • Vincenzo Fragola
  • Teshome Abegaz
  • Stefano Lucattini
  • Atalilt Halifom
  • Eskedar Tadesse
  • Micheal Berhe
  • Paola De Castro
  • Massimiliano Di Gregorio
  • Katherina Pugliese
  • Roberta Terlizzi
  • Stefano Vella
  • Hagos Godefay



In Ethiopia data concerning the influence of gender on mortality and loss to follow-up are controversial. Our study is intended to further investigate gender-related differences in antiretroviral therapy (ART) outcomes in Tigray (Ethiopia).


We used data from the “Cohort of African people Starting Antiretroviral therapy’ (CASA) project, a prospective study of a cohort of HIV-positive patients who started ART in Tigray. The study population included HIV-positive patients starting ART between January 2013 and December 2015. Baseline characteristics were compared between men and women using Kruskal Wallis t-test and Chi-squared test. Kaplan-Meier method was used to estimate the probability of mortality and loss to follow-up for men and women. Univariate and multivariate Cox Proportional Hazards models were used to compare differences in ART outcomes by gender.


The study population included 1622 patients, 1003 (61.84%) women and 619 (38.16) men. Median follow-up time was 2.6 years and 2.1 years, respectively for women and men. In the multivariate analysis men had a significantly higher risk of loss to follow-up than women (aHR 2.83, 95% CI: 2.00-4.01); but no significant sex differences in mortality was observed (aHR 1.19, 95% CI: 0.76-1.84).


Findings showed gender-related differences in loss to follow-up, not in mortality. Several structural and social factors may influence the gender difference in loss to follow-up. However, specific investigations are needed to get a better understanding of the reasons why men are more likely to be lost to follow-up than women and programmes with a gender-oriented approach should be implemented.


UNAIDS(2017). UNAIDS DATA,2017. Available:

Fox MP1, Rosen S. Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries: Systematic Review and Meta-analysis 2008-2013 . J Acquir Immune Defic Syndr. 2015; May 1;69(1):98-108. PMID:25942461

Jiang H,1 Yin J,1 Fan Y,1 Liu J,1 Zhang Z,1 Li Liu L, et al. Gender difference in advanced HIV disease and late presentation according to European consensus definitions. Sci. Rep. 2015; 5: 14543. PMID: 26412578

Braitstein P, Boulle A, Nash D, Brinkhof MW, Dabis F, Laurent C, et al. Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration. J Womens Health (Larchmt). 2008; Jan-Feb;17(1):47-55. PMID:18240981

Centers for Disease Control and Prevention(2013). Differences Between HIV-Infected Men and Women in Antiretroviral Therapy Outcomes — Six African Countries, 2004–2012. CDC, 2013. Available:

Hawkins C, Chalamilla G, Okuma J, Spiegelman D, Hertzmark E, Aris E, et al. Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzanian setting. AIDS 2011; Jun 1;25(9):1189-97. PMID:21505309

Druyts E, Dybul M, Kanters S, Nachega J, Birungi J, Ford N, et al. Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis. AIDS 2013; Jan 28;27(3):417-25. PMID:22948271

Mosha F, Muchunguzi V, Matee M, Sangeda RZ, Vercauteren J, Nsubuga P et al. Gender differences in HIV disease progression and treatment outcomes among HIV patients one year after starting antiretroviral treatment (ART) in Dar es Salaam, Tanzania. BMC Public Health.2013;

Jan 15;13:38 . PMID: 23320567

Brinkhof MW, Dabis F, Myer L, Bangsberg DR, Boulle A, Nash D, et al. Early loss of HIV-infected patients on potent antiretroviral therapy programmes in lower-income countries.

Bull World Health Organ. 2008; Jul;86(7):559-67. PMID:18670668

Samji H1, Cescon A1, Hogg RS2, Modur SP3, Althoff KN3, Buchacz K4, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One 2013; Dec 18;8(12):e81355. PMID:24367482. PMID:24367482

Central Statistical Agency ,Ethiopia and ICF International, USA, 2012 . Ethiopia Demographic and Health Survey 2011. Available:

Bucciardini R1, Fragola V1, Abegaz T2, Lucattini S1, Halifom A3, Tadesse E2 ,et al. Predictors of attrition from care at 2 years in a prospective cohort of HIV-infected adults in Tigray, Ethiopia. BMJ Glob Health. 2017; Aug 6;2(3). PMID:29082011

Setegn T, Takele A, Gizaw T, Nigatu D, Haile D. Predictors of Mortality among Adult Antiretroviral Therapy Users in Southeastern Ethiopia: Retrospective Cohort Study.

AIDS Res Treat. 2015; 2015:148769. doi: 10.1155/2015/148769

Tadesse K,Haile F, Hiruy N. Predictors of Mortality among Patients Enrolled on Antiretroviral Therapy in Aksum Hospital, Northern Ethiopia: A Retrospective Cohort Study.

PLoS One 2014; Jan 31;9(1):e87392. PMID: 24498093

Ayalew MB. Mortality and Its Predictors among HIV Infected Patients Taking Antiretroviral Treatment in Ethiopia: A Systematic Review. AIDS Res Treat. 2017; 2017: 5415298. PMID: 29214077

Megerso A, Garoma S, Eticha T, Workineh T, Daba S, Tarekegn M,et al. Predictors of loss to follow-up in antiretroviral treatment for adult patients in the Oromia region, Ethiopia. HIV AIDS (Auckl) 2016; Apr 26;8:83-92. PMID: 27175095

Tadesse K, Haile F, Predictors of Loss to Follow Up of Patients Enrolled on Antiretroviral Therapy: A Retrospective Cohort Study Predictors of mortality among patients enrolled on antiretroviral therapy in Aksum hospital, northern Ethiopia: a retrospective cohort study. J AIDS Clin Res. 2014; 5:12. doi:10.4172/2155-6113.1000393

Berheto TM, Haile DB,1 Mohammed S. Predictors of Loss to follow-up in Patients Living with HIV/AIDS after Initiation of Antiretroviral Therapy. N Am J Med Sci. 2014; Sep; 6(9): 453–459. PMID: 25317390

Wubshet M, Berhane Y, Worku A, Kebede Y. Perception and predictors of quality of life among HIV patients attending art clinics in northwest Ethiopia: a prospective longitudinal study. Ethiopian Medical Journal 2014; Jul;52(3):119-127. PMID:25812285

Fekade D, Weldegebreal T, Teklu AM, Damen M, Abdella S, Baraki N,et al.

Predictors of Survival among Adult Ethiopian Patients in the National ART Program at Seven University Teaching Hospitals: A Prospective Cohort Study.Ethiop J Health Sci. 2017; Feb;27(Suppl 1):63-71. doi: 10.4314/ejhs.v27i1.7S

Seyoum D, Degryse JM, Kifle YG, Taye A, Tadesse M, Birlie B,et al. Risk Factors for Mortality

among Adult HIV/AIDS Patients Following Antiretroviral Therapy in Southwestern Ethiopia: An bn

Assessment through Survival Models. Int J Environ Res Public Health. 2017; Mar 12;14(3).


Alemu AW, Sebastián MS. Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia. Glob Health Action. 2010; Oct 29;3. doi: 10.3402/gha.v3i0.5398.

Tsegaye E, Worku A. Assessment of antiretroviral treatment outcome in public hospitals, South Nations Nationalities and Peoples Region, Ethiopia. Ethiop. J. Health Dev. 2011;25(2). Available:

Hawkins C1, Chalamilla G, Okuma J, Spiegelman D, Hertzmark E, Aris E, et al. Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzanian setting. AIDS 2011; Jun 1;25(9):1189-97. doi: 10.1097/QAD.0b013e3283471deb

Mills EJ, Bakanda C, Birungi J, Chan K, Hogg RS, Ford , et al. Male gender predicts mortality in a large cohort of patients receiving antiretroviral therapy in Uganda.

J Int AIDS Soc. 2011; Nov 3;14:52. PMID: 22050673

Cornell M, Schomaker M, Garone DB, Giddy J, Hoffmann CJ, Lessells R, et al.

Gender differences in survival among adult patients starting antiretroviral therapy in South Africa: A Multicentre Cohort Study. PLoS Med. 2012; 9(9):e1001304. PMID:22973181

Takarinda KC, Harries AD, Shiraishi RW, Mutasa-Apollo T, Abdul-Quader A, Mugurungi O.

Gender-related differences in outcomes and attrition on antiretroviral treatment among an HIV-infected patient cohort in Zimbabwe: 2007-2010. Int J Infect Dis. 2015; Jan;30:98-105. PMID: 25462184

Castilho JL, Melekhin VV, Sterling TR. Sex differences in HIV outcomes in the highly active antiretroviral therapy era: A Systematic Review. AIDS Res Hum Retroviruses 2014; May;30(5):446-56. doi: 10.1089/AID.2013.0208. Review. PMID:24401107

Mangili A, Murman DH, Zampini AM, Wanke CA. Nutrition and HIV infection: review of weight loss and wasting in the era of highly active antiretroviral therapy from the nutrition for healthy living cohort. Clin Infect Dis. 2006 Mar 15;42(6):836-42

Gupta A, Nadkarni G, Yang WT, Chandrasekhar A, Gupte N, Bisson GP, et al. Early mortality in adults initiating antiretroviral therapy (ART) in low- and middle-income countries (LMIC): a systematic review and meta-analysis. PLoS One 2011;6(12):e28691. PMID:22220193

The Global BMI Mortality Collaboration (2016). Body-mass index and all-cause mortality: individual- participant-data meta-analysis of 239 prospective studies in four continents. Lancet 2016; 388: 776–786. DOI:

Kwantwi LB, Tunu BK, Boateng D, Quansah DY. Body Mass Index, Haemoglobin, and Total Lymphocyte Count as a Surrogate for CD4 Count in Resource Limited Settings. J Biomark 2017;2017:7907352. doi: 10.1155/2017/7907352

Edathodu J, Ali B, Alrajhi AA. CD4 validation for the World Health Organization classification and clinical staging of HIV/AIDS in a developing country. Int J Infect Dis. 2009 Mar;13(2):243-6. PMID:18945632

Damtew B, Mengistie B, Alemayehu T. Survival and determinants of mortality in adult HIV/Aids patients initiating antiretroviral therapy in Somali Region, Eastern Ethiopia. Pan Afr Med J. 2015; Oct 14;22:138 PMID: 26889319

Poka-Mayap V, Pefura-Yone EW, Kengne AP, Kuaban C.Mortality and its determinants among patients infected with HIV-1 on antiretroviral therapy in a referral centre in Yaounde, Cameroon: a retrospective cohort study. BMJ Open 2013; Jul 13;3(7) PMID:23852140

Moh R, Danel C, Messou E, Ouassa T, Gabillard D, Anzian A,et al. Incidence and determinants of mortality and morbidity following early antiretroviral therapy initiation in HIV-infected adults in West Africa. AIDS 2007; Nov 30;21(18):2483-2491. PMID:18025885

World Health Organization (2015). Consolidated guidelines on HIV testing services.WHO,2015. Available:

Jerene D, Endale A, Hailu Y, Lindtjørn B Predictors of early death in a cohort of Ethiopian patients treated with HAART. BMC Infect Dis. 2006 Sep 1;6:136. PMID:16948852

Melaku Z, Lamb MR, Wang C, Lulseged S, Gadisa T, Ahmed S, et al. Characteristics and outcomes of adult Ethiopian patients enrolled in HIV care and treatment: a multi-clinic observational study. BMC Public Health 2015; May 3;15:462. doi: 10.1186/s12889-015-1776-4

Ochieng-Ooko V, Ochieng D, Sidle JE, Holdsworth M, Wools-Kaloustian K, SiikaAM,et al.. Influence of gender on loss to follow-up in a large HIV treatment programme in western Kenya. Bull World Health Organ. 2010; Sep 1;88(9):681-688. DOI:10.2471/BLT.09.064329

Weigel R, Estill J, Egger M, Harries AD, Makombe S, Tweya H, et al.Mortality and loss to follow-

up in the first year of ART: Malawi national ART programme. AIDS 2012; Jan 28;26(3):365-373.

doi: 10.1097/QAD.0b013e32834ed814

Sylvie Lambert, Martin Ravallion, Dominique Van de Walle. Intergenerational Mobility and Interpersonal Inequality in an African Economy. PSE Working Papers n°2014-02. D31, I31, O15. 2014

Korthuis PT, Fiellin DA, McGinnis KA, Skanderson M, MS,3 Justice AC, MD, PhD,2,4 Gordon A, et

al. Unhealthy alcohol and illicit drug use are associated with decreased quality of HIV care. J Acquir

Immune Defic Syndr. 2012; October 1; 61(2): 171–178. doi:10.1097/QAI.0b013e31826741aa

Arnsten JH1, Demas PA, Grant RW, Gourevitch MN, Farzadegan H, Howard AA, et al.

Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users. J Gen Intern Med. 2002; May;17(5):377-381. PMID:12047736

Skovdal M1, Campbell C, Madanhire C, Mupambireyi Z. Masculinity as a barrier to men’s use of HIV services in Zimbabwe.Global Health 2011. May 15;7:13. doi: 10.1186/1744-8603-7-13






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