Background: In August 2011, in accordance with current WHO guidelines, South Africa expanded its ART guidelines to allow treatment initiation at CD4 values ≤350 cells/mm3 for all adults and adolescents. While mortality and morbidity are known to be improved at initiating at higher CD4 levels, the impact on patient loss to follow-up (LTFU) remains unclear. Using data from a Johannesburg primary health clinic that has offered routine ART initiation at CD4 ≤350 since 2010, we examine the impact of initiating treatment at higher CD4 counts on patient outcomes. Methods: Using electronic medical records from Witkoppen Health and Welfare Centre, we created a retrospective cohort of 1457 adult patients initiating ART from April-December 2010. We compared patient outcomes for those who initiated at baseline CD4 values ≤200 versus 201-350 cells/mm3 one year after initiating ART. Results: Half (51.6%) the sample initiated ≤200 and half (48.4%) at 201-350 cells/mm3. Median (IQR) baseline CD4 by group was 107 cells/mm3 (56-156) versus 270 cells/mm3 (239-307). Median age and nationality were consistent by group; the 201-350 group had more females and pregnancy at initiation; the ≤200 group had more prevalent TB. One year post-initiation, 207 (14.2%) were LTFU (failure to return to the clinic for ≥3 months after the last scheduledvisit), 27 (1.9%) were confirmed dead, and 44 (3.0%) had acquired tuberculosis. Adjusting for age, sex, pregnancy at initiation, and prevalent TB, initiating at 201-350 resulted in lower LTFU (HR:0.71, 95% CI: 0.53-0.94), as well as substantially reduced mortality (HR:0.34, 95% CI:0.14-0.85) and incident tuberculosis (HR:0.38, 95% CI:0.20-0.73). Conclusions: This is one of the first studies from a routine clinical setting to demonstrate that initiating ART at a CD4 count 201-350 as allowed under South Africa’s new ART guidelines yields improvements in patient outcomes, including fewer deaths, improved retention, and reduced incident tuberculosis.
Conference: AIDS 29012, Washington DC, USA