How varying CD4 criteria for treatment initiation was associated with mortality of HIV-patients? A retrospective analysis of electronic health records from Andhra Pradesh, India.

Ram Bajpai,Himanshu K Chaturvedi,Josip Car

doi:10.7189/jogh.10.010408

Abstract

BackgroundHIV treatment and care services were scaled up in 2007 in India with objective to increase HIV-care coverage. CD4 count based criteria was mainly used for treatment initiation with increasing threshold in later years. Therefore, this paper aimed to evaluate the survival by varying CD4 criteria for antiretroviral treatment (ART) initiation among of HIV-positive patients, and independent factors associated with the mortality.MethodsThis retrospective cohort study included 127 949 HIV-positive patients aged ≥15 years, who initiated ART between 2007 and 2013 in Andhra Pradesh state, India. The patient’s demographic and clinical characteristics were extracted from the patient’s health records from electronic Computerized Management Information System Software (CMIS). Incidence of mortality/100 person-years was calculated for CD4 and treatment initiation categories. Kaplan-Meier and multivariable Cox-regression analyses were used to explore the association.ResultsMedian CD4 count was 172 (inter-quartile range (IQR) = 102-240) at the time of treatment initiation, and 19.3% of them had ≤ 100 CD4 count. Incidence of mortality for the period 2007-08 (CD4 ≤ 200 cells/mm3) was 8.5/100 person-years compared to 6.4/100 person-years at risk for the period 2012 onwards (CD4 ≤ 350 cells/mm3). Earlier thresholds for treatment initiation showed higher risk of mortality (2007-08 (CD4 ≤ 200 cells/mm3), adjusted hazard ratio (HR): 1.86, 95% confidence interval (CI): 1.68-2.07; 2009-11 (CD4 ≤ 250 cells/mm3), HR = 1.67, 95% CI = 1.51-1.85) compared to 2012 onwards (CD4 ≤ 350 cells/mm3) criteria for treatment initiation.ConclusionsIncreasing CD4 threshold for treatment initiation over time was independently associated with lower risk of mortality. More efforts are required to detect and treat early, monitoring of follow-ups, promote health education to improve ART adherence, and provide supportive environment that encourages HIV-infected patients to disclose their HIV status in confidence.

Highlights

Pulmonary – start ART within 2 weeks of initiation of ATT from all patients with CD4 ≤ 350 cells/ml
WHO clinical stage III and IV patients will be strictly monitored for adverse effects of nevirapine
In the absence of a CD4 count, do not delay ART initiation if the patient is clinically eligible according to the WHO Clinical Staging Criteria

Summary

Introduction

Pulmonary – start ART within 2 weeks of initiation of ATT from all patients with CD4 ≤ 350 cells/ml (for patients with CD4 more than 350, defer ART). 1. For HIV infected adult/ adolescents (including pregnant women) Treat if CD4 ≤ 200 cells/ml (b) Clinical Stage III and IV 2. For HIV and tuberculosis (TB) co-infected patients

Results

Conclusion