The future role of CD4 cell count for monitoring antiretroviral therapy

Ford, Nathan; Meintjes, Graeme; Pozniak, Anton; Bygrave, Helen; Hill, Andrew; Peter, Trevor; Davies, Mary Ann; Grinsztejn, Beatriz; Calmy, Alexandra; Kumarasamy, N.; Phanuphak, Praphan; Beaudrap, Pierre De; Vitória, Marco; Doherty, Meg; Stevens, Wendy; Siberry, George K.

doi:10.1016/s1473-3099(14)70896-5

Cited by 123 publications

(104 citation statements)

References 48 publications

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“…Increased CD4 cell count is a key marker of immune restoration [80–83]. Vigorous improvements in CD4 cell levels following ART initiation have been reported in both clinical trials and observational studies from high resource countries [84–86].…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012

et al. 2016

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BackgroundThe Nigerian Antiretroviral therapy (ART) program started in 2004 and now ranks among the largest in Africa. However, nationally representative data on outcomes have not been reported.MethodsWe evaluated retrospective cohort data from a nationally representative sample of adults aged ≥15 years who initiated ART during 2004 to 2012. Data were abstracted from 3,496 patient records at 35 sites selected using probability-proportional-to-size (PPS) sampling. Analyses were weighted and controlled for the complex survey design. The main outcome measures were mortality, loss to follow-up (LTFU), and retention (the proportion alive and on ART). Potential predictors of attrition were assessed using competing risk regression models.ResultsAt ART initiation, 66.4 percent (%) were females, median age was 33 years, median weight 56 kg, median CD4 count 161 cells/mm3, and 47.1% had stage III/IV disease. The percentage of patients retained at 12, 24, 36 and 48 months was 81.2%, 74.4%, 67.2%, and 61.7%, respectively. Over 10,088 person-years of ART, mortality, LTFU, and overall attrition (mortality, LTFU, and treatment stop) rates were 1.1 (95% confidence interval (CI): 0.7–1.8), 12.3 (95%CI: 8.9–17.0), and 13.9 (95% CI: 10.4–18.5) per 100 person-years (py) respectively. Highest attrition rates of 55.4/100py were witnessed in the first 3 months on ART. Predictors of LTFU included: lower-than-secondary level education (reference: Tertiary), care in North-East and South-South regions (reference: North-Central), presence of moderate/severe anemia, symptomatic functional status, and baseline weight <45kg. Predictor of mortality was WHO stage higher than stage I. Male sex, severe anemia, and care in a small clinic were associated with both mortality and LTFU.ConclusionModerate/Advanced HIV disease was predictive of attrition; earlier ART initiation could improve program outcomes. Retention interventions targeting men and those with lower levels of education are needed. Further research to understand geographic and clinic size variations with outcome is warranted.

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Section: Discussionmentioning

confidence: 99%

Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012

et al. 2016

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“…The latest ART guidelines for South Africa, the country with the largest number of people on ART, recommend stopping routine CD4 monitoring in patients stable on ART, and several other high HIV burden countries are considering a similar change in policy [1]. Several programmes in high-income settings have documented substantial cost savings that could be made if routine CD4 monitoring was stopped [12,15,19].…”

Section: Resultsmentioning

confidence: 99%

CD4 changes among virologically suppressed patients on antiretroviral therapy: a systematic review and meta‐analysis

Ford

Stinson

Gale

et al. 2015

Journal of the International AIDS Society

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IntroductionThe effectiveness of antiretroviral therapy (ART) is assessed by measuring CD4 cell counts and viral load. Recent studies have questioned the added value of routine CD4 cell count measures in patients who are virologically suppressed.MethodsWe systematically searched three databases and two conference sites up to 31 October 2014 for studies reporting CD4 changes among patients who were on ART and virologically suppressed. No geographic, language or age restrictions were applied.Results and discussionWe identified 12 published and 1 unpublished study reporting CD4 changes among 20,297 virologically suppressed patients. The pooled proportion of patients who experienced an unexplained, confirmed CD4 decline was 0.4% (95% CI 0.2–0.6%). Results were not influenced by duration of follow-up, age, study design or region of economic development. No studies described clinical adverse events among virologically suppressed patients who experienced CD4 declines.ConclusionsThe findings of this review support reducing or stopping routine CD4 monitoring for patients who are immunologically stable on ART in settings where routine viral load monitoring is provided.

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“…Such cohorts exist in low-, middle- and high-income countries 17 , 18 . The second data set is collected in most countries, as CD4+ cell count is an important parameter for the decisions of ART initiation and clinical management, 19 even in countries implementing ART initiation regardless of CD4+ count levels. Thus, our approach can be used to estimate the delay in ART initiation in most settings.…”

Section: Discussionmentioning

confidence: 99%

New indicators for delay in initiation of antiretroviral treatment: estimates for Cameroon

Ndawinz

Anglaret

Delaporte

et al. 2015

Bull. World Health Organ.

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ObjectiveTo propose two new indicators for monitoring access to antiretroviral treatment (ART) for human immunodeficiency virus (HIV); (i) the time from HIV seroconversion to ART initiation, and (ii) the time from ART eligibility to initiation, referred to as delay in ART initiation. To estimate values of these indicators in Cameroon.MethodsWe used linear regression to model the natural decline in CD4+ T-lymphocyte (CD4+ cell) numbers in HIV-infected individuals over time. The model was fitted using data from a cohort of 351 people in Côte d’Ivoire. We used the model to estimate the time from seroconversion to ART initiation and the delay in ART initiation in a representative sample of 4154 HIV-infected people who started ART in Cameroon between 2007 and 2010.FindingsIn Cameroon, the median CD4+ cell counts at ART initiation increased from 140 cells/μl (interquartile range, IQR: 66 to 210) in 2007–2009 to 163 cells/μl (IQR: 73 to 260) in 2010. The estimated average time from seroconversion to ART initiation decreased from 10.4 years (95% confidence interval, CI: 10.3 to 10.5) to 9.8 years (95% CI: 9.6 to 10.0). Delay in ART initiation increased from 3.4 years (95% CI: 3.1 to 3.7) to 5.8 years (95% CI: 5.6 to 6.2).ConclusionThe estimated time to initiate ART and the delay in ART initiation indicate that progress in Cameroon is insufficient. These indicators should help monitor whether public health interventions to accelerate ART initiation are successful.

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The future role of CD4 cell count for monitoring antiretroviral therapy

Cited by 123 publications

References 48 publications

Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012

Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012

CD4 changes among virologically suppressed patients on antiretroviral therapy: a systematic review and meta‐analysis

New indicators for delay in initiation of antiretroviral treatment: estimates for Cameroon

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