Abstract
IntroductionSex differences have already been reported in sub‐Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow‐up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults.MethodsWe used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no‐follow‐up and 10‐year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively.ResultsA total of 71,283 patients (65.8% women) contributed to 310,007 person‐years of follow‐up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10‐year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow‐up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10‐year attrition throughout the 10‐year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow‐up, whereas men failed to reach it even at the end of the 10‐year follow‐up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%).ConclusionsIn West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex‐adapted are needed for patients in care to monitor attrition, detect early high‐risk groups so that they can stay in care with a durably controlled infection.
Highlights
Sex differences have already been reported in sub-Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow-up was usually limited to the first two to three years after ART initiation
We evaluated 10-year attrition and immunological response to ART by sex among HIV-infected adults followed in large HIV care programmes throughout West Africa
In the 10-year following ART initiation, we investigated the association between sex and immunological response, defined by the evolution of CD4 count
Summary
In 2016, the World Health Organization recommended that all HIV-infected patients be treated with antiretroviral therapy (ART) irrespective of CD4-cell counts and clinical stage [1]. The International epidemiology Databases to Evaluate AIDS (IeDEA) group reported that only 52% of African patients were retained in care five years following ART initiation. This rate improved to 66% after accounting for undocumented mortality and self-transfers [6]. Retention in care and immunological response in ARTtreated patients have been reported already in many African settings, but less evidence is available from West Africa where the burden of HIV is somewhat lower than in other African regions but where the coverage of care and ART programmes is far less advanced [27]. We evaluated 10-year attrition and immunological response to ART by sex among HIV-infected adults followed in large HIV care programmes throughout West Africa
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