Immunodeficiency at Antiretroviral Therapy Start: Five-Year Adult Data (2012–2017) Based on Evolving National Policies in Rural Mozambique

Arinze, Folasade; Gong, Wu; Green, Ann; Schacht, Caroline De; Carlucci, James G.; Silva, Wilson; Claquin, Gael; Tique, José A.; Stefanutto, Marzio; Graves, Erin; Rompaey, Sara Van; Alvim, Maria Fernanda Sardella; Tomo, Simão; Moon, Troy D.; Wester, Carolyn

doi:10.1089/aid.2019.0043

Cited by 2 publications

(3 citation statements)

References 29 publications

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“…Remarkably, despite an increase of the median CD4 count to 253 cells/µL in 2018 and 2019, it remained below the threshold of late presentation—350 cells/μL—throughout the study. Other studies in SSA confirm our findings: in rural Mozambique an increase by 68 cells/µL was observed after adoption of test and treat guidelines [ 34 ]. Interestingly, a study in Eswatini showed that despite an increase of the median CD4 cell count by 37 cells/µL retention in care remained similar under treat-all versus previous standard of care [ 35 ], which implies that HIV care goes beyond ART and should integrate early diagnosis, prophylaxis, and treatment of OIs as well as intensified adherence support.…”

Section: Discussionsupporting

confidence: 90%

Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization “Test and Treat” Guidelines

Stöger

Katende

Mapesi

et al. 2022

Open Forum Infectious Diseases

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Background Information about burden, characteristics, predictors, and outcomes of advanced human immunodeficiency virus disease (AHD) is scarce in rural settings of sub-Saharan Africa. Human immunodeficiency virus (HIV) infections and associated deaths remain high despite specific guidelines issued by the World Health Organization (WHO). Methods Burden of AHD and 6-month death/loss to follow-up (LTFU) were described among 2498 antiretroviral therapy (ART)–naive nonpregnant people with HIV (PWH) aged >15 years enrolled in the Kilombero Ulanga Antiretroviral Cohort in rural Tanzania between 2013 and 2019. Baseline characteristics associated with AHD and predictors of death/LTFU among those with AHD were analyzed using multivariate logistic and Cox regression, respectively. Results Of the PWH, 62.2% had AHD at diagnosis (66.8% before vs 55.7% after national uptake of WHO “test and treat” guidelines in 2016). At baseline, older age, male sex, lower body mass index, elevated aminotransferase aspartate levels, severe anemia, tachycardia, decreased glomerular filtration rate, clinical complaints, impaired functional status, and enrollment into care before 2018 were independently associated with AHD. Among people with AHD, incidence of mortality, and LTFU were 16 and 34 per 100 person-years, respectively. WHO clinical stage 3 or 4, CD4 counts <100 cells/µL, severe anemia, tachypnea, and liver disease were associated with death/LTFU. Conclusions More than 50% of PWH enrolled in our cohort after test and treat implementation still had AHD at diagnosis. Increasing HIV testing and uptake and implementation of the WHO-specific guidelines on AHD for prevention, diagnosis, treatment of opportunistic infections, and reducing the risks of LTFU are urgently needed to reduce morbidity and mortality.

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Section: Discussionsupporting

confidence: 90%

Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization “Test and Treat” Guidelines

Stöger

Katende

Mapesi

et al. 2022

Open Forum Infectious Diseases

View full text Add to dashboard Cite

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“…There was no statistically significant relationship between sex and severe immunodeficiency in our multivariable model; however, there was a nonsignificant trend toward boys being more likely to have severe immunodeficiency than girls. Other studies have also noted sex-based differences in HIV outcomes: barriers to engagement of adult men in HIV services in LMICs have been reported [44][45][46] ; men in Zambézia were more likely to initiate ART with severe immunodeficiency in a recent study 23 ; and adolescent boys in Zambézia enrolled into care with more advanced HIV disease, took longer to initiate ART, and were more likely to experience pre-ART loss to follow-up than adolescent girls. 47 Taken together with the fact that only 42% of children in this cohort were boys, there are possibly sex-based disparities that need to be addressed to ensure timely access to pediatric HIV care and treatment for both boys and girls.…”

Section: Discussionmentioning

confidence: 96%

“…By contrast, it is expected that HIV-related immunodeficiency should be less severe among CLHIV initiating ART in the Test and Start era, wherein universal and immediate treatment is recommended, regardless of immunologic or clinical status. However, previous studies of HIV-related immunodeficiency among children relative to ART program maturation included only children starting ART before 2013, 21,22 and more recent studies focused solely on adults, 23,24 so less is known about CLHIV receiving HIV care and treatment in Mozambique in recent years. Therefore, the objectives of this evaluation were to describe the degree of immunodeficiency and to identify risk factors for enrolling in HIV care and starting ART with severe immunodeficiency among children during the period of evolving ART initiation policies in Zambézia Province, Mozambique.…”

Section: Introductionmentioning

confidence: 99%

CD4 Trends With Evolving Treatment Initiation Policies Among Children Living With HIV in Zambézia Province, Mozambique, 2012–2018

Carlucci

Schacht

Graves

et al. 2022

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background:Historically, antiretroviral therapy (ART) initiation was based on CD4 criteria, but this has been replaced with "Test and Start" wherein all people living with HIV are offered ART. We describe the baseline immunologic status among children relative to evolving ART policies in Mozambique.Methods:This retrospective evaluation was performed using routinely collected data. Children living with HIV (CL aged 5–14 years) with CD4 data in the period of 2012–2018 were included. ART initiation “policy periods” corresponded to implementation of evolving guidelines: in period 1 (2012–2016), ART was recommended for CD4 <350 cells/mm3; during period 2 (2016–2017), the CD4 threshold increased to <500 cells/mm3; Test and Start was implemented in period 3 (2017–2018). We described temporal trends in the proportion of children with severe immunodeficiency (CD4 <200 cells/mm3) at enrollment and at ART initiation. Multivariable regression models were used to estimate associations with severe immunodeficiency.Results:The cohort included 1815 children with CD4 data at enrollment and 1922 at ART initiation. The proportion of children with severe immunodeficiency decreased over time: 20% at enrollment into care in period 1 vs. 16% in period 3 (P = 0.113) and 21% at ART initiation in period 1 vs. 15% in period 3 (P = 0.004). Children initiating ART in period 3 had lower odds of severe immunodeficiency at ART initiation compared with those in period 1 [adjusted odds ratio (aOR) = 0.67; 95% CI: 0.51 to 0.88]. Older age was associated with severe immunodeficiency at enrollment (aOR = 1.13; 95% CI: 1.06 to 1.20) and at ART initiation (aOR = 1.14; 95% CI: 1.08 to 1.21).Conclusions:The proportion of children with severe immunodeficiency at ART initiation decreased alongside more inclusive ART initiation guidelines. Earlier treatment of children living with HIV is imperative.

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Immunodeficiency at Antiretroviral Therapy Start: Five-Year Adult Data (2012–2017) Based on Evolving National Policies in Rural Mozambique

Cited by 2 publications

References 29 publications

Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization “Test and Treat” Guidelines

Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization “Test and Treat” Guidelines

CD4 Trends With Evolving Treatment Initiation Policies Among Children Living With HIV in Zambézia Province, Mozambique, 2012–2018

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