Initiation of ART at higher CD4 counts under South Africa’s revised antiretroviral therapy guidelines results in improved patient outcomes

By Kate Clouse  Audrey Pettifor  Dr Mhairi Maskew  Jean Bassett  Annelies Van Rie  Frieda Behets  Cynthia Gay  Professor Ian Sanne  Matthew Fox  |  | 

Abstract

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

 

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