Mortality and its predictors among adolescents and adults on antiretroviral therapy in the era of test-and-treat, Ethiopia: a retrospective cohort study.

BACKGROUND: HIV/AIDS remains a leading cause of morbidity and mortality in resource-limited settings. Although several studies have assessed mortality among patients on antiretroviral therapy (ART), evidence from Ethiopia during the test-and-treat era, where all diagnosed individuals start ART immediately regardless of clinical stage or CD4 count, is limited.

METHODS: A retrospective cohort study was conducted at public hospitals in the West Arsi Zone, involving 446 adolescents and adults on ART between August 2016 and June 2019. Participants were selected by stratified random sampling at three randomly selected hospitals. Data were extracted from the patient cards and electronic databases. Cox proportional hazard regression was fitted to identify predictors of mortality.

RESULTS: Among 446 patients followed for 13,860 person-months, early mortality predominated, with 28 (59.57%) deaths occurring within the first 6 months of ART initiation. Overall, 47 (10.54%) patients died, yielding an all-cause mortality rate of 4.07 (95% CI: 3.14–5.19) per 100 person-years. The cumulative survival at the end of follow-up was 87.37% (95% CI: 83.46–90.41). The predictors of mortality were age group > 35 (AHR 2.51, 95% CI: 1.17–5.37), rural residence (AHR 1.77, 95% CI: 1.09–2.89), WHO clinical stage 3 or 4 (AHR 4.16, 95% CI: 1.89–9.16), bedridden functional status (AHR 8.48, 95% CI: 3.19–22.52), TB coinfection (AHR 3.69, 95% CI: 1.95–6.98), moderate or severe anemia (AHR 4.15, 95% CI: 2.16–7.97), and non-disclosure of HIV status (AHR 3.86, 95% CI: 1.93–7.72).

CONCLUSION: This study highlights substantial early mortality among patients receiving ART and identified key clinical and demographic predictors of mortality. These findings underscore the need for targeted interventions to improve survival outcomes. Policy makers and program managers should prioritize early diagnosis and treatment initiation, strengthen tuberculosis screening programs and disclosure counseling, and ensure close monitoring of patients with advanced disease, anemia, and those residing in rural areas.

TRIAL REGISTRATION: Clinical trial number: Not applicable.

SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12879-026-12919-1.