Abstract
BackgroundPredictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs.MethodsThe HACART study was a multi-center observational clinic-based cohort study of 2585 adults who started HAART between April 2008 and February 2009. A total of 628 patients were randomly selected at 12 months for immuno-virologic analyses.ResultsVirologic suppression rate (<400 copies/ml) was 76.7%, immunologic recovery rate (CD4 change from baseline ≥50 cells/mm3) was 77.4% and immuno-virologic discordance rate was 33%. In multivariate logistic regression, virologic failure was associated with age <30 years (OR 1.79; 95% CI: 1.17-2.67, p=0.03), anemia (Hemoglobin < 10 g/dl) (OR 1.71; 95% CI: 1.22-2.61, p=0.03), poor adherence (OR 3.82; 95% CI: 2.17-5.97, p=0.001), and post-secondary education (OR 0.60; 95% CI: 0.30-0.86, p=0.02). Immunologic failure was associated with male gender (OR 1.46; 95% CI: 1.04-2.45, p=0.04), and age <30 years (OR 1.50; 95% CI: 1.11-2.39, p=0.03). Virologic failure with immunologic success (VL-/CD4+) was associated with anemia (OR 1.80; 95% CI: 1.13-2.88, p=0.03), poor adherence (OR 3.90; 95% CI: 1.92-8.24, p=0.001), and post-secondary education (OR 0.40; 95% CI: 0.22-0.68, p=0.005).ConclusionsAlthough favorable immuno-virologic outcomes could be achieved in this large ART program, immuno-virologic discordance was observed in a third of the patients. Focusing on intensified treatment preparation and adherence, young patients, males, persons with low educational status and most importantly baseline anemia assessment and management may help address predictors of poor immuno-virologic outcomes, and improve overall HIV program impact. Viral load testing in addition to the CD4 testing should be considered to identify, characterize and address negative immuno-virologic outcomes and discordance.
Highlights
Predictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs
In resource-constrained settings, the World Health Organization (WHO) currently does not recommend routine HIV viral load (VL) testing, in part due to the cost and complex infrastructure needed for reliable results [5,7] but proposes the use of clinical and CD4+ lymphocyte-based criteria to guide treatment decision
The HIV Acquired Immunodeficiency Syndrome (AIDS) Care and Anti-Retroviral Therapy (HACART) study was a large multi-center observational clinic-based cohort study that described the predictors of loss to follow-up, immuno-virologic outcomes, immuno-virologic discordance and sub-optimal drug adherence within the AIDS Care and Treatment in Nigeria (ACTION) project
Summary
Predictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs. In resource-constrained settings, the World Health Organization (WHO) currently does not recommend routine HIV viral load (VL) testing, in part due to the cost and complex infrastructure needed for reliable results [5,7] but proposes the use of clinical and CD4+ lymphocyte-based criteria to guide treatment decision. Immuno-virologic discordance occurs when viral load test results used to assess virologic failure do not correspond to expected CD4 cell count results used to assess immunologic failure, and this discordance is associated with poor clinical outcomes
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