9. HIV in Uganda
• Prevalence 6.7%
• 1.2M HIV-infected
• 120.000 new infections/yr
• 54% on ART
• ± 63.000 deaths/yr
Global AIDS Response Progress Report, 2012
10. General Objectives
To study the mortality in HIV-infected adults:
• the causes of death
• methods to establish the causes of death
11. Specific objectives
• Autopsy literature review
• Evaluate trends in cause of death over time
• Study acceptance of complete autopsy
• Compare clinical to autopsy cause of death
• Evaluate accuracy en practice of needle autopsy
12. Autopsy causes of death in HIV positive individuals
in Sub-Saharan Africa and correlation with clinical
diagnoses; an overview of the literature
Janneke A. Cox, Robert L. Lukande, Sebastian Lucas, Ann M. Nelson,
Eric Van Marck, Robert Colebunders
AIDS Reviews 2010; 12(4): 183‐94
13. Results
• 20 studies, 1992-2008, 9 complete autopsy series
• 593 HIV-infected adults
• Main cause of death: tuberculosis (32-45%)
• 66% pulmonary infection, 20% cerebral infection
• Clinical diagnosis tuberculosis:
Sensitivity 43-80%, Specificity 67-76%
• All pre-ART and majority pre-CTX
14. Temporal Trends in All Cause Mortality in Adults
attending an Urban HIV-clinic in Uganda: a
Retrospective Chart-review
Janneke A. Cox, Daniel Kiggundu, Lana Elpert, Graeme Meintjes,
Robert Colebunders, Stella Alamo
Submitted
15. Methods
• Urban HIV-treatment clinic
• Inclusion: adults with known death date
• Retrospective chart review to assign cause of death
• Trends in proportions in 4 death-categories over time
19. Conclusion
In deceased urban HIV-infected adults
• Decrease in the proportion of deaths from communicable
conditions and AIDS-defining malignancies over time
• Communicable conditions and AIDS-defining malignancies
remained the main death category
20. Autopsy acceptance rate and reasons for decline in
Mulago Hospital, Kampala, Uganda
Janneke A. Cox, Robert L. Lukande, Alice Kateregga, Harriet Mayanja-Kizza,
Yukari C. Manabe, Robert Colebunders
Tropical Medicine and International Health 2011; 16(8): 1015‐18
An Autopsy Study describing Causes of Death and
comparing Clinico-Pathological Findings among
Hospitalized Patients in Kampala, Uganda
Janneke A. Cox*, Robert L. Lukande*, Ann M. Nelson, Harriet Mayanja-Kizza,
Robert Colebunders, Eric Van Marck, Yukari C. Manabe
*Contributed equally
PLoS One. 2012; 7(3): e33685
21. Methods
• Setting: ID-GI medical ward Mulago Hospital, Kampala
• Inclusion: All deaths study ward
• Exclusion: No relative to consent or relative <18 yrs old
• Sample size: Based on study period 4 months
1. Collect clinical information postmortem from ward doctor,
chart and relatives
2. Request consent autopsy
3. Perform complete autopsy
23. Reasons for decline
• Not wanting to delay the burial 58%
• No use to know the cause of death 16%
• Being satisfied with the clinical cause of death 10%
• Cultural reasons 6%
• Religious reasons 1%
• Other
26. Correlation clinical-autopsy diagnosis
• HIV-positives
– 12% clinically confirmed
– 27% highly suspected
– 16% considered
– 45% not considered
• HIV-negatives
– 17% clinically highly suspected
– 42% considered
– 42% not considered
27. • HIV-positives
– 12% clinically confirmed
– 27% highly suspected
– 16% considered
– 45% not considered
• Dual diagnosis
• Atypical presentation
Correlation clinical-autopsy diagnosis
28. Conclusion
• Complete autopsy is acceptable
• Main reason for decline untimely request
• HIV-infected patient die of clinically undiagnosed
infections
• Disseminated TB main cause of death
Emphasises the importance of autopsy
29. So, should we advocate for autopsies
for everybody, everywhere?
30. Needle Autopsy to Establish the Cause of Death in HIV-
infected Hospitalized Adults in Uganda: A Comparison to
Complete Autopsy
Janneke A. Cox, Robert L. Lukande, Sam Kalungi, Eric Van Marck, Koen Van de
Vijver, Andrew Kambugu, Ann Nelson, Yukari Manabe, Robert Colebunders
Journal of Acquired Immune Deficiency Syndromes 2014; 67(2):169-76
Practice of Percutaneous Needle Autopsy; a Descriptive
Study reporting Experiences from Uganda
Janneke A. Cox, Robert L. Lukande, Sam Kalungi, Koen Van de Vijver, Eric Van
Marck, Ann M. Nelson, Asafu Munema, Yukari Manabe, Robert Colebunders
Submitted
31. Methods
• Setting: Medicine wards Mulago hospital,
Kampala
• Inclusion:
– Adults (>18yrs)
– HIV +: self reported or in-hospital tested
• Exclusion:
– Post-partum death
– Death after trauma
• Sample size:
– 18 wks, 5 inclusion/week
32. Study procedures
Needle autopsy -> Complete autopsy
Cause of death?Cause of death? Cause of death?
Deceased HIV+ adult
US guided Needle autopsy ->
38. Conclusion
• Needle autopsy obtains adequate tissue for histological
review in majority of cases and organs
• Needle autopsy can be learned
• Concordance of 50% in major diagnosis between blind
needle and complete autopsy
• Ultrasound guidance improves tissue yield for some
organs but does not improve concordance
39. Conclusions and Recommendations
Causes of death
Treatable HIV-related diseases cause the majority
of deaths in HIV-infected adults
• Reducing these is priority:
• Symptoms based therapy
• Sensitive point of care diagnostics
• Awareness of HIV serostatus
• Linkage to care
• Timely ART initiation
• Monitoring ART
40. Conclusions and Recommendations
Methods
Clinical diagnosis correlate poorly to autopsy diagnosis
• Caution in interpreting mortality statistics
Complete autopsies are acceptable
• Request and perform when feasible
Needle autopsy are a feasible and reasonable accurate
method to establish the cause of death
• Refine methods
• Adjust tool to population
41. Acknowledgements
Uganda
Robert Lukande
Sam Kalungi
Asafu Munema
Eva Mbwilo
Edrisa Katende
Betty Namwase
Andrew Kambugu
Stella Alamo
Daniel Kiggundu
Belgium
Robert Colebunders
Eric Van Marck
Koen Van de Vijver
Martin Lammens
Christophe Hermans
USA
Yukari Manabe
Ann Nelson
Lana Elpert
