Initiating patients on antiretroviral therapy at CD4 cell counts above 200 cells/Âµl is associated with improved treatment outcomes in South Africa

Zeinecker, Jennifer; Orrell, Catherine; Wood, Robin

Initiating patients on antiretroviral therapy at CD4 cell counts above 200 cells/Âµl is associated with improved treatment outcomes in South Africa

Journal Article

2010

Journal Title

AIDS

Link to Journal

http://journals.lww.com/aidsonline/pages/default.aspx

Publisher

Wolters Kluwer Health

Publisher

University of Cape Town

Department

Department of Medicine

Faculty

Faculty of Health Sciences

Abstract

Observational cohort study. Methods Patients presenting to primary care clinics with CD4 cell counts <350 cells/mm3 were randomized to either doctor- or nurse-managed HIV care and followed for at least two years after ART initiation. Clinical and laboratory outcomes were compared by baseline CD4 count. Results 812 patients were followed for a median of 27.5 months and 36% initiated with a CD4 count >200. While 10% of patients failed virologically (VF), the risk was nearly double among those with a CD4 ≤200 vs. >200 (12.2% vs. 6.8%). 21 deaths occurred, with a five-fold increased risk for the low CD4 group (3.7% vs. 0.7%). After adjustment, those with a CD4 count ≤200 had twice the risk of death/VF (HR 1.9; 95% CI: 1.1–3.3) and twice the risk of incident tuberculosis (HR: 1.90; 95% CI: 0.89–4.04) as those >200. Those with either a CD4 ≤200 (HR 2.1; 1.2–3.8) or a WHO IV condition (HR 2.9; 0.93–8.8) alone had a two to three-fold increased risk of death/VF vs. those with neither, but those with both conditions had a 4-fold increased risk (HR 3.9; 95% CI: 1.9–8.1). We observed some increased loss to follow-up among those initiating <200 (HR 0.79; 95% CI: 0.50–1.25). Conclusions Patients initiating ART with higher CD4 counts had reduced mortality, tuberculosis and less virologic failure than those initiated at lower CD4 counts. Our data support increasing CD4 count eligibility criteria for ART initiation.