Effects of CD4 Cell Counts and Viral Load Testing on Mortality Rates in Patients With HIV Infection Receiving Antiretroviral Treatment: An Observational Cohort Study in Rural Southwest China

Shen, Zhiyong; Zhu, Qingqing; Tang, Zhenzhu; Pan, Stephen W.; Zhang, Heng; Jiang, He; Chen, Yi; Lan, Guanghua; Xing, Hui; Liao, Lingjie; Feng, Yue; Ruan, Yuhua; Shao, Yiming

doi:10.1093/cid/ciw146

Cited by 18 publications

(18 citation statements)

References 31 publications

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“…The coefficients for the confounding ( a i ) effect is −0.64 while the CD4 effect is 0.11 on survival. Therefore, unmeasured confounders, e.g., patient characteristics related to underlying health (comorbidity, clinical stage, and treatment history) 49,50 , may be correlated with both CD4 and survival, which leads to the correlation between CD4 and survival. In contrast, CD4 itself has no direct significant effect on survival.…”

Section: Discussionmentioning

confidence: 99%

Exploring causality mechanism in the joint analysis of longitudinal and survival data

Liu

Zheng

Kang

2018

Statistics in Medicine

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In many biomedical studies, disease progress is monitored by a biomarker over time, eg, repeated measures of CD4 in AIDS and hemoglobin in end-stage renal disease patients. The endpoint of interest, eg, death or diagnosis of a specific disease, is correlated with the longitudinal biomarker. In this paper, we examine and compare different models of longitudinal and survival data to investigate causal mechanisms, specifically, those related to the role of random effects. We illustrate the methods by data from two clinical trials: an AIDS study and a liver cirrhosis study.

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Section: Discussionmentioning

confidence: 99%

Exploring causality mechanism in the joint analysis of longitudinal and survival data

Liu

Zheng

Kang

2018

Statistics in Medicine

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“…There is ample evidence showing that routine VL monitoring can provide an early and more accurate diagnosis of treatment failure when compared to clinical and immunological monitoring [32, 33], but evidence regarding the value of VL monitoring as compared to immunological monitoring in reducing mortality among patients on ART has been mixed [34–38]. Availability of, and access to, VL testing is still limited due to the requirements of expensive laboratory equipment, complex sample collection and processing, and the need for highly trained personnel [39].…”

Section: Discussionmentioning

confidence: 99%

Feasibility of antiretroviral treatment monitoring in the era of decentralized HIV care: a systematic review

et al. 2017

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BackgroundRegular monitoring of HIV patients who are receiving antiretroviral therapy (ART) is required to ensure patient benefits and the long-term effectiveness and sustainability of ART programs. Prompted by WHO recommendations for expansion and decentralization of HIV treatment and care in low and middle income countries, we conducted a systematic review to assess the feasibility of treatment monitoring in these settings.MethodsA comprehensive search strategy was developed using a combination of MeSH and free text terms relevant to HIV treatment and care, health service delivery, health service accessibility, decentralization and other relevant terms. Five electronic databases and two conference websites were searched to identify relevant studies conducted in LMICs, published in English between Jan 2006 and Dec 2015. Outcomes of interest included the proportion of patients who received treatment monitoring and health system factors related to monitoring of patients on ART under decentralized HIV service delivery models.ResultsFrom 5363 records retrieved, twenty studies were included in the review; all but one was conducted in sub-Saharan African countries. The majority of studies (15/20) had relatively short follow-up duration (≤24 months), and only two studies were specifically designed to assess treatment monitoring practices. The most frequently studied follow-up period was 12 months and a wide range of treatment monitoring coverage was observed. The reported proportions of patients on ART who received CD4 monitoring ranged from very low (6%; N = 2145) to very high (95%; N = 488). The median uptake of viral load monitoring was 86% with studies in program settings reporting coverage as low as 14%. Overall, the longer the follow-up period, the lower the proportion of patients who received regular monitoring tests; and programs in rural areas reported low coverage of laboratory monitoring. Moreover, uptake in the context of research had significantly better where monitoring was done by dedicated research staff. In the absence of point of care (POC) testing, the limited capacity for blood sample transportation between clinic and laboratory and poor quality of nursing staff were identified as a major barrier for treatment monitoring practice.ConclusionsThere is a paucity of data on the uptake of treatment monitoring, particularly with longer-term follow-up. Wide variation in access to both virological and immunological regular monitoring was observed, with some clinics in well-resourced settings supported by external donors achieving high coverage. The feasibility of treatment monitoring, particularly in decentralized settings of HIV treatment and care may thus be of concern and requires further study. Significant investment in POC diagnostic technologies and, improving the quality of and training for nursing staff is required to ensure effective scale up of ART programs towards the targets of 90-90-90 by the year 2020.Electronic supplementary materialThe online version of this article (doi:10.1186/s12981-017-0...

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“…In China, HIV-related mortality has significantly declined since the National Free Antiretroviral Treatment Program (NFATP) was initiated in 2002 and rapidly scaled up 22–26 . Following updated WHO ART guidelines in 2010, China further expanded ART services in order to reduce overall mortality among HIV infected patients, prevent transmission among key populations, and provide ART to those with higher CD4 counts 7, 10, 26 .…”

Section: Introductionmentioning

confidence: 99%

Effects of high CD4 cell counts on death and attrition among HIV patients receiving antiretroviral treatment: an observational cohort study

Tang

Pan

Ruan

et al. 2017

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Current WHO guidelines recommend initiating ART regardless of CD4+ cell count. In response, we conducted an observational cohort study to assess the effects of pre-ART CD4+ cell count levels on death, attrition, and death or attrition in HIV treated patients. This large HIV treatment cohort study (n = 49,155) from 2010 to 2015 was conducted in Guangxi, China. We used a Cox regression model to analyze associations between pre-ART CD4+ cell counts and death, attrition, and death or attrition. The average mortality and ART attrition rates among all treated patients were 2.63 deaths and 5.32 attritions per 100 person-years, respectively. Compared to HIV patients with <350 CD4+ cells/mm3 at ART initiation, HIV patients with >500 CD4+ cells/mm3 at ART initiation had a significantly lower mortality rate (Adjusted hazard ratio: 0.56, 95% CI: 0.40–0.79), but significantly higher ART attrition rate (AHR: 1.17, 95% CI: 1.03–1.33). Results from this study suggest that HIV patients with high CD4+ cell counts at the time of ART initiation may be at greater risk of treatment attrition. To further reduce ART attrition, it is imperative that patient education and healthcare provider training on ART adherence be enhanced and account for CD4 levels at ART initiation.

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Effects of CD4 Cell Counts and Viral Load Testing on Mortality Rates in Patients With HIV Infection Receiving Antiretroviral Treatment: An Observational Cohort Study in Rural Southwest China

Abstract: Our study suggests that CD4 cell counts can be reduced to twice during the first year of ART and be reduced or stopped for patients who have achieved virologic suppression or immunologic stability after 12 months of treatment.

Cited by 18 publications

References 31 publications

Exploring causality mechanism in the joint analysis of longitudinal and survival data

Exploring causality mechanism in the joint analysis of longitudinal and survival data

Feasibility of antiretroviral treatment monitoring in the era of decentralized HIV care: a systematic review

Effects of high CD4 cell counts on death and attrition among HIV patients receiving antiretroviral treatment: an observational cohort study

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