Causes of death in people living with HIV in the post 95 -95 -95 era: Lessons from five AIDS Healthcare Foundation clinics in Eswatini

Abstract Background Eswatini has a high HIV prevalence in adults (24.8%), and despite achieving HIV epidemic control, AIDS-related deaths are still high at 200 per 100,000 population. This study, therefore, describes the causes of death among people living with HIV (PLHIV) receiving care at five clinics in Eswatini. Methods Data of clients receiving antiretroviral therapy (ART) from five AIDS Healthcare Foundation (AHF) Clinics in Eswatini who died was analysed to describe the causes of death. Clients' records were included if they received treatment from any of the five clinics from January 1, 2021, to June 30, 2022. Clients' sociodemographic, clinical, and specific cause of death data were extracted from their clinical records into an Excel spreadsheet for mortality reporting and audits. The different causes of death were categorised and descriptive, and comparative analysis was done using Stata 15 and R. Odds ratio significant at p<0.05 (with 95% confidence interval) to estimate the different associations between the client's characteristics and the four leading causes of death. Results Of 257 clients, 52.5% (n=135) were males, and the median age was 47 years (IQR: 38, 59). The leading causes of death were non-communicable diseases (NCDs) (n=59, 23.0%), malignancies (n=37, 14.4%), Covid-19 (n=36, 14.0%) and advanced HIV disease (AHD) (n=24, 9.3%). Patients aged ≥60 years (OR 0.08; 95% CI: 0.004, 0.44) had lower odds of death from AHD than ≥40 years, and those who had been on ART for 12 – 60 months (OR 0.01; 95% CI: 0.0006, 0.06) and >60 months (OR 0.006; 95% CI: 0.0003, 0.029) had lower odds of death from AHD compared to those on ART for <12 months. Patients aged ≥40 years had higher odds of dying from COVID-19, while females (OR 2.64; 95% CI: 1.29, 5.70) had higher odds of death from malignancy. Conclusion Most patients who died were aged 40 years and above and died from an NCD, malignancy, COVID-19 and AHD-related cause. This indicates a need to expandprevention, screening, and integration of treatment for NCDs and cancers into HIV services. Specific interventions targeting younger PLHIV will limit their risks for AHD.