Abstract
BackgroundData on determinants of long-term disease progression in HIV-infected patients on antiretroviral therapy (ART) are limited in low and middle-income settings.MethodsEffects of current CD4 count, viral load and haemoglobin and diagnosis of AIDS-defining events (ADEs) after start of combination ART (cART) on death and new ADEs were assessed using Poisson regression, in patient aged ≥18 years within a multi-centre cohort in Thailand.ResultsAmong 1,572 patients, median follow-up from cART initiation was 4.4 (IQR 3.6–6.3) years. The analysis of death was based on 60 events during 6,573 person-years; 30/50 (60%) deaths with underlying cause ascertained were attributable to infections. Analysis of new ADE included 192 events during 5,865 person-years; TB and Pneumocystis jiroveci pneumonia were the most commonly presented first new ADE (35% and 20% of cases, respectively). In multivariable analyses, low current CD4 count after starting cART was the strongest predictor of death and of new ADE. Even at CD4 above 200 cells/mm3, survival improved steadily with CD4, with mortality rare at ≥500 cells/mm3 (rate 1.1 per 1,000 person-years). Haemoglobin had a strong independent effect, while viral load was weakly predictive with poorer prognosis only observed at ≥100,000 copies/ml. Mortality risk increased following diagnosis of ADEs during cART. The decline in mortality rate with duration on cART (from 21.3 per 1,000 person-years within first 6 months to 4.7 per 1,000 person-years at ≥36 months) was accounted for by current CD4 count.ConclusionsPatients with low CD4 count or haemoglobin require more intensive diagnostic and treatment of underlying causes. Maintaining CD4≥500 cells/mm3 minimizes mortality. However, patient monitoring could potentially be relaxed at high CD4 count if resources are limited. Optimal ART monitoring strategies in low-income settings remain a research priority. Better understanding of the aetiology of anaemia in patients on ART could guide prevention and treatment.
Highlights
By the end of 2009, 5 of the 33 million HIV-infected patients in low- and middle-income countries were receiving antiretroviral therapy (ART) [1]
The cohort began in 1999, recruiting women from trials on prevention of mother-to-child transmission of HIV (PMTCT) [23,24], and later extended to partners of these women and any HIV-infected adults presenting at participating sites
This study was based on a well-run, long-term ART programme involving a wide range of public hospitals throughout Thailand, with good quality data collection including accurate ascertainment of AIDS diagnoses and cause of death for most patients
Summary
By the end of 2009, 5 of the 33 million HIV-infected patients in low- and middle-income countries were receiving antiretroviral therapy (ART) [1]. Minimizing long-term morbidity and mortality in patients on ART becomes increasingly important as treatment programmes mature, standard of care improves and more effective drug combinations are available. This has led to increased debate on optimal approaches for monitoring antiretroviral treatment in low-income settings [2]. Data on determinants of long-term disease progression in HIV-infected patients on antiretroviral therapy (ART) are limited in low and middle-income settings
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