Citation
Clouse, Kate; Pettifor, Audrey E.; Maskew, Mhairi; Bassett, Jean F.; Van Rie, Annelies T.; Gay, Cynthia L.; Behets, Frieda M.-T. F.; Sanne, Ian; & Fox, Matthew P. (2013). Initiating Antiretroviral Therapy When Presenting with Higher CD4 Cell Counts Results in Reduced Loss to Follow-up in a Resource-Limited Setting. AIDS, 27(4), 645-650. PMCID: PMC3646627Abstract
OBJECTIVE: In August 2011, South Africa expanded its adult antiretroviral treatment (ART) guidelines to allow treatment initiation at CD4 values =350 cells/mul. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up.DESIGN: An observational cohort study.
METHODS: We analyzed routine data of 1430 adult patients initiating ART from April-December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 =350 cells/mul since 2010. We compared loss to follow-up (>/=3 months late for the last scheduled visit), death and incident tuberculosiswithin one year of ART initiation for those initiating at CD4 values =200 versus 201-350 cells/mul.
RESULTS: Half (52.0%) of patients presented in the lower CD4 group (=200 cells/mul, median: 105cells/mul, IQR: 55-154) and initiated ART, and 48.0% in the higher group (CD4 201-350 cells/mul, median: 268cells/mul, IQR: 239-307). The proportion of females and pregnant women was greater in the high CD4 group; the lower CD4 group included more patients with prevalent tuberculosis. Among men and non-pregnant women, initiating at 201-350 cells/mulwas associated with 26-42% reduced loss to follow-up compared to those initiating =200 cells/mul. We found no CD4 effect among pregnant women. Risk of mortality (aHR 0.34, 95%CI 0.13-0.84) and incident tuberculosis (aHR 0.44, 95%CI 0.23-0.85) was lower among the higher CD4 group.
CONCLUSIONS: This is one of the first studies from a routine clinical setting to demonstrate South Africa's 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition.
URL
http://dx.doi.org/10.1097/QAD.0b013e32835c12f9Reference Type
Journal ArticleYear Published
2013Journal Title
AIDSAuthor(s)
Clouse, KatePettifor, Audrey E.
Maskew, Mhairi
Bassett, Jean F.
Van Rie, Annelies T.
Gay, Cynthia L.
Behets, Frieda M.-T. F.
Sanne, Ian
Fox, Matthew P.