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Cardone KM, Dudek S, Keat K, Bradford Y, Cindi Z, Daar ES, Gulick R, Riddler SA, Lennox JL, Sinxadi P, Haas DW, Ritchie MD. Lymphocyte Count Derived Polygenic Score and Interindividual Variability in CD4 T-cell Recovery in Response to Antiretroviral Therapy. PACIFIC SYMPOSIUM ON BIOCOMPUTING. PACIFIC SYMPOSIUM ON BIOCOMPUTING 2024; 29:594-610. [PMID: 38160309 PMCID: PMC10764076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Access to safe and effective antiretroviral therapy (ART) is a cornerstone in the global response to the HIV pandemic. Among people living with HIV, there is considerable interindividual variability in absolute CD4 T-cell recovery following initiation of virally suppressive ART. The contribution of host genetics to this variability is not well understood. We explored the contribution of a polygenic score which was derived from large, publicly available summary statistics for absolute lymphocyte count from individuals in the general population (PGSlymph) due to a lack of publicly available summary statistics for CD4 T-cell count. We explored associations with baseline CD4 T-cell count prior to ART initiation (n=4959) and change from baseline to week 48 on ART (n=3274) among treatment-naïve participants in prospective, randomized ART studies of the AIDS Clinical Trials Group. We separately examined an African-ancestry-derived and a European-ancestry-derived PGSlymph, and evaluated their performance across all participants, and also in the African and European ancestral groups separately. Multivariate models that included PGSlymph, baseline plasma HIV-1 RNA, age, sex, and 15 principal components (PCs) of genetic similarity explained ∼26-27% of variability in baseline CD4 T-cell count, but PGSlymph accounted for <1% of this variability. Models that also included baseline CD4 T-cell count explained ∼7-9% of variability in CD4 T-cell count increase on ART, but PGSlymph accounted for <1% of this variability. In univariate analyses, PGSlymph was not significantly associated with baseline or change in CD4 T-cell count. Among individuals of African ancestry, the African PGSlymph term in the multivariate model was significantly associated with change in CD4 T-cell count while not significant in the univariate model. When applied to lymphocyte count in a general medical biobank population (Penn Medicine BioBank), PGSlymph explained ∼6-10% of variability in multivariate models (including age, sex, and PCs) but only ∼1% in univariate models. In summary, a lymphocyte count PGS derived from the general population was not consistently associated with CD4 T-cell recovery on ART. Nonetheless, adjusting for clinical covariates is quite important when estimating such polygenic effects.
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Affiliation(s)
- Kathleen M Cardone
- Department of Genetics, University of Pennsylvania, Philadelphia, PA, USA
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Belay DM, Bayisa B, Abera M. Association of Substance Use with Immunological Response to Antiretroviral Therapy in HIV-Positive Patients from Southwest Ethiopia: A Prospective Observational Study. Int J Gen Med 2022; 15:8437-8450. [PMID: 36483781 PMCID: PMC9724579 DOI: 10.2147/ijgm.s389010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/19/2022] [Indexed: 11/03/2023] Open
Abstract
Background Use of psychoactive substances by HIV-positive patients in the course of antiretroviral drug treatment has become a public health problem globally. Substance use (alcohol, nicotine, and khat) during the course of treatment results in interactions with drugs that lead to undesired treatment outcomes. This condition is understudied, and the consequences of substance use among patients on antiretroviral treatment are not well explored. Methods A prospective observational study was conducted among people on antiretroviral therapy (ART) at Jimma University Medical Center in southwest Ethiopia from April 20 to November 27, 2019. Data were collected using the World Health Organization's alcohol, smoking, and substance involvement screening test among adults who have followed antiretroviral therapy for a minimum of 6 months. Logistic regression analysis was done to identify factors associated with immunological response. The inadequate immunological response was defined as patients who were unable to achieve or maintain a CD4 cell count of >350 cells/mm³ after the 6-months of follow-up. Results Of the 332 patients enrolled, a majority (64.2%) of the respondents were females. The mean (±SD) age of the patients was 38.5 ± 9.5 years. The proportion of participants with a high level of health risk due to alcohol use was 8.4%, while 63.8% of them were non-alcohol users with no health risk. In multivariable logistic regression analysis, moderate and high levels of health risks from alcohol use were significantly associated with increased odds of inadequate immunological response (AOR: 2.9; 95% CI, 1.1-7.4) and (AOR: 4.3; 95% CI, 1.2-14.8), respectively, but the level of health risk from khat and cigarette use showed no association with inadequate immunological response in this study. Conclusion Moderate and high levels of health risk from alcohol use were independently associated with inadequate immunological response. People living with HIV/AIDS should regularly be screened for and be educated about substance use and its potential negative impact on CD4 cell recovery.
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Affiliation(s)
- Dagmawi Mekonnen Belay
- Jimma University Medical Center, Clinical Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Bodena Bayisa
- Department of Clinical Pharmacy, School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Mubarek Abera
- Department of Psychiatry, Faculty of Medical Sciences, Jimma University, Jimma, Ethiopia
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Fiseha T, Ebrahim H, Ebrahim E, Gebreweld A. CD4+ cell count recovery after initiation of antiretroviral therapy in HIV-infected Ethiopian adults. PLoS One 2022; 17:e0265740. [PMID: 35324948 PMCID: PMC8947242 DOI: 10.1371/journal.pone.0265740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background CD4+ cell count recovery after effective antiretroviral therapy (ART) is an important determinant of both AIDS and non-AIDS morbidity and mortality. Data on CD4+ cell count recovery after initiation of ART are still limited in Sub-Saharan Africa. The aim of this study was to assess CD4+ cell count recovery among HIV-infected adults initiating ART in an Ethiopian setting. Methods A retrospective cohort study of HIV-infected adults initiating ART between September 2008 and June 2019 was carried out. CD4+ cell count recovery was defined as an increase in CD4+ cell count of >100 cells/mm3 from baseline or achievement of a CD4+ cell count >500 cells/mm3 at 12 months after ART initiation. Factors associated with CD4+ cell count recovery were evaluated using logistic regression analysis. Results Of the 566 patients included in this study, the median baseline CD4+ cell count was 264 cells/mm3 (IQR: 192–500). At 12 months after ART initiation, the median CD4+ cell count increased to 472 cells/mm3, and the proportion of patients with CD4+ cell count < 200 cells/mm3 declined from 28.3 to 15.0%. A total of 58.0% of patients had an increase in CD4+ cell count of >100 cells/mm3 from baseline and 48.6% achieved a CD4+ cell count >500 cells/mm3 at 12 months. Among patients with CD4+ cell counts < 200, 200–350 and >350 cells/mm3 at baseline, respectively, 30%, 43.9% and 61.7% achieved a CD4+ cell count >500 cells/mm3 at 12 months. In multivariable analysis, poor CD4+ cell count recovery (an increase of ≤100 cells/mm3 from baseline) was associated with older age, male sex, higher baseline CD4+ cell count and zidovudine-containing initial regimen. Factors associated with poor CD4+ cell count recovery to reach the level >500 cells/mm3 included older age, male sex and lower baseline CD4+ cell count. Conclusions CD4+ cell count failed to recover in a substantial proportion of adults initiating ART in this resource-limited setting. Older age, male sex and baseline CD4+ cell count are the dominant factors for poor CD4+ cell count recovery. Novel therapeutic approaches are needed focusing on high risk patients to maximize CD4+ cell count recovery and improve outcomes during therapy.
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Affiliation(s)
- Temesgen Fiseha
- Department of Clinical Laboratory Science, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
- * E-mail:
| | - Hussen Ebrahim
- Department of Clinical Laboratory Science, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Endris Ebrahim
- Department of Clinical Laboratory Science, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Angesom Gebreweld
- Department of Medical Laboratory Science, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Characteristics of suboptimal immune response after initiating antiretroviral therapy among people living with HIV with a pre-treatment CD4 T cell count <200 cells/mm 3 in Thailand. J Virus Erad 2020; 6:100005. [PMID: 33251023 PMCID: PMC7646671 DOI: 10.1016/j.jve.2020.100005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 02/08/2020] [Accepted: 07/16/2020] [Indexed: 01/28/2023] Open
Abstract
Background Complete recovery of the CD4 T cell count is uncommon among chronically HIV-infected individuals with very low pre-treatment CD4 count. We studied the prevalence of chronically immune recovery and its associated factors including immune characteristics chronic HIV-infected Thais. Methods Treatment-naïve participants (n = 375) from the HIV-NAT 006 cohort with a pre-treatment CD4 T cell count after initiating antiretroviral therapy (ART) and having achieved a suppressed viremia (HIV-RNA level < 400 copies/mL) were retrospectively followed at the Thai Red Cross AIDS Research Centre, Bangkok, Thailand. Suboptimal immune recovery (SIR) was defined as having a CD4+ T cell count <200 cells/mm3 for 3 years after ART initiation. A case-control sub-study matched for age, sex and pre-ART CD4 T cell count was conducted to compare immunological characteristics between SIR (n = 17) and non-SIR (n = 24) participants. Immunological biomarkers such as interleukin-7 (IL-7) and soluble CD14 (sCD14) and other covariates including cytomegalovirus (CMV) DNA level, baseline hemoglobin level, hepatitis B and C co-infections, and T cell subsets associated with immune activation and exhaustion were evaluated. Results Among 375 participants with pre-ART CD4 T cell counts < 200 cells/mm3, the prevalence of SIR was 39.7%, 19.7% and 7.7% at years 1, 2 and 3 after starting ART, respectively. In a multivariate analysis, a pre-ART CD4 T cell count ≤100 cells/mm3 (adjusted odds ratio [aOR] 9.45, 95% CI 2.92–30.61, p < 0.001), older age (aOR 1.07, 95% CI 1.01–1.13, p = 0.029) and baseline HIV-RNA level (aOR 0.36, 95% CI 0.21–0.59, p < 0.001) were independently associated with SIR at year 3 after ART initiation. In the matched case-control sub-study (cases = 17, controls = 24), there was a higher prevalence of hepatitis C co-infection (18.8% vs. 0%, p = 0.05), lower sCD14 levels (mean, 6.23 vs. 6.27 log10 pg/mL, p = 0.04), lower CD8 T cell counts (mean, 514 vs. 876, p = 0.0003), lower CD4/CD8 T cell ratio (mean, 0.27 vs. 0.41, p = 0.01) and higher expression of PD1 on CD8+ T cells (74.2% vs. 65.1%, p = 0.02) observed in SIR participants compared to their non-SIR counterparts at year 3 after ART initiation. Conclusions Nearly 10% of the study participants who had achieved virological suppression failed to recover a CD4 T cell count > 200 cells/mm3 after 3 years of ART which was with a very low pre-ART CD4 T cell count and older age. The long-term clinical outcomes of SIR participants need to be further explored.
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Wolday D, Legesse D, Kebede Y, Siraj DS, McBride JA, Striker R. Immune recovery in HIV-1 infected patients with sustained viral suppression under long-term antiretroviral therapy in Ethiopia. PLoS One 2020; 15:e0240880. [PMID: 33091053 PMCID: PMC7580989 DOI: 10.1371/journal.pone.0240880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/06/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND There is very little data on long-term immune recovery responses in patients on suppressive antiretroviral therapy (ART) in the setting of sub-Saharan Africa (SSA). Thus, we sought to determine CD4+ T-cell, CD8+ T-cell and CD4/CD8 ratio responses in a cohort of HIV infected individuals on sustained suppressive ART followed up for more than a decade. METHODS The cohort comprised adult patients who started ART between 2001 and 2007 and followed for up to 14 years. Trends in median CD4+ T-cells, CD8+ T-cells and CD4/CD8 ratio were reviewed retrospectively. Poisson regression models were used to identify factors associated with achieving normalized T-cell biomarkers. Kaplan-Meier curves were used to estimate the probability of attaining normalized counts while on suppressive ART. RESULTS A total of 227 patients with a median duration of follow-up on ART of 12 (IQR: 10.5-13.0) years were included. CD4 cell count increased from baseline median of 138 cells (IQR: 70-202) to 555 cells (IQR: 417-830). CD4 cell increased continuously up until 5 years, after which it plateaued up until 14 years of follow up. Only 69.6% normalized their CD4 cell count within a median of 6.5 (IQR: 3.0-10.5) years. In addition, only 15.9% of the cohort were able to achieve the median reference CD4+ T-cell threshold count in Ethiopians (≈760 cells/μL). CD8+ T-cell counts increased initially until year 1, after which continuous decrease was ascertained. CD4/CD8 ratio trend revealed continuous increase throughout the course of ART, and increased from a median baseline of 0.14 (IQR: 0.09-0.22) to a median of 0.70 (IQR: 0.42-0.95). However, only 12.3% normalized their ratio (≥ 1.0) after a median of 11.5 years. In addition, only 8.8% of the cohort were able to achieve the median reference ratio of healthy Ethiopians. CONCLUSION Determination of both CD4+ and CD8+ T-cells, along with CD4/CD8 ratio is highly relevant in long-term follow-up of patients to assess immune recovery. Monitoring ratio levels may serve as a better biomarker risk for disease progression among patients on long-term ART. In addition, the findings emphasize the relevance of initiation of ART at the early stage of HIV-1 infection.
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Affiliation(s)
- Dawit Wolday
- Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | | | - Yazezew Kebede
- Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Dawd S. Siraj
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Joseph A. McBride
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Robert Striker
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin, Madison, Wisconsin, United States of America
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Chammartin F, Dao Ostinelli CH, Anastos K, Jaquet A, Brazier E, Brown S, Dabis F, Davies MA, Duda SN, Malateste K, Nash D, Wools-Kaloustian K, von Groote PM, Egger M. International epidemiology databases to evaluate AIDS (IeDEA) in sub-Saharan Africa, 2012-2019. BMJ Open 2020; 10:e035246. [PMID: 32414825 PMCID: PMC7232622 DOI: 10.1136/bmjopen-2019-035246] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/21/2020] [Accepted: 04/14/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The objectives of the International epidemiology databases to evaluate AIDS (IeDEA) are to (i) evaluate the delivery of combination antiretroviral therapy (ART) in children, adolescents and adults in sub-Saharan Africa, (ii) to describe ART regimen effectiveness, durability and tolerability, (iii) to examine HIV-related comorbidities and coinfections and (iv) to examine the pregnancy-related and HIV-related outcomes of women on ART and their infants exposed to HIV or ART in utero or via breast milk. PARTICIPANTS IeDEA is organised in four regions (Central, East, Southern and West Africa), with 240 treatment and care sites, six data centres at African, European and US universities, and almost 1.4 million children, adolescents and adult people living with HIV (PLWHIV) enrolled. FINDINGS TO DATE The data include socio-demographic characteristics, clinical outcomes, opportunistic events, treatment regimens, clinic visits and laboratory measurements. They have been used to analyse outcomes in PLWHIV-1 or PLWHIV-2 who initiate ART, including determinants of mortality, of switching to second-line and third-line ART, drug resistance, loss to follow-up and the immunological and virological response to different ART regimens. Programme-level estimates of mortality have been corrected for loss to follow-up. We examined the impact of coinfection with hepatitis B and C, and the epidemiology of different cancers and of (multidrug resistant) tuberculosis, renal disease and of mental illness. The adoption of 'Treat All', making ART available to all PLWHIV regardless of CD4+ cell count or clinical stage was another important research topic. FUTURE PLANS IeDEA has formulated several research priorities for the 'Treat All' era in sub-Saharan Africa. It recently obtained funding to set up sentinel sites where additional data are prospectively collected on cardiometabolic risks factors as well as mental health and liver diseases, and is planning to create a drug resistance database.
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Affiliation(s)
| | - Cam Ha Dao Ostinelli
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Kathryn Anastos
- Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Antoine Jaquet
- French National Research Institute for Sustainable Development (IRD), Inserm, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Steven Brown
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Francois Dabis
- French National Research Institute for Sustainable Development (IRD), Inserm, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karen Malateste
- French National Research Institute for Sustainable Development (IRD), Inserm, UMR 1219, University of Bordeaux, Bordeaux, France
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Per M von Groote
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
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Yang X, Su B, Zhang X, Liu Y, Wu H, Zhang T. Incomplete immune reconstitution in HIV/AIDS patients on antiretroviral therapy: Challenges of immunological non-responders. J Leukoc Biol 2020; 107:597-612. [PMID: 31965635 PMCID: PMC7187275 DOI: 10.1002/jlb.4mr1019-189r] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/25/2019] [Accepted: 11/13/2019] [Indexed: 12/14/2022] Open
Abstract
The morbidity and mortality of HIV type-1 (HIV-1)-related diseases were dramatically diminished by the grounds of the introduction of potent antiretroviral therapy, which induces persistent suppression of HIV-1 replication and gradual recovery of CD4+ T-cell counts. However, ∼10-40% of HIV-1-infected individuals fail to achieve normalization of CD4+ T-cell counts despite persistent virological suppression. These patients are referred to as "inadequate immunological responders," "immunodiscordant responders," or "immunological non-responders (INRs)" who show severe immunological dysfunction. Indeed, INRs are at an increased risk of clinical progression to AIDS and non-AIDS events and present higher rates of mortality than HIV-1-infected individuals with adequate immune reconstitution. To date, the underlying mechanism of incomplete immune reconstitution in HIV-1-infected patients has not been fully elucidated. In light of this limitation, it is of substantial practical significance to deeply understand the mechanism of immune reconstitution and design effective individualized treatment strategies. Therefore, in this review, we aim to highlight the mechanism and risk factors of incomplete immune reconstitution and strategies to intervene.
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Affiliation(s)
- Xiaodong Yang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Bin Su
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Xin Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Yan Liu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory for HIV/AIDS Research, Beijing, China
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CD4 count recovery and associated factors among individuals enrolled in the South African antiretroviral therapy programme: An analysis of national laboratory based data. PLoS One 2019; 14:e0217742. [PMID: 31150489 PMCID: PMC6544279 DOI: 10.1371/journal.pone.0217742] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 05/17/2019] [Indexed: 12/02/2022] Open
Abstract
Background We describe CD4 count recovery among HIV positive individuals who initiated antiretroviral therapy (ART) with and without severe immune suppression using complete laboratory data from South Africa’s national HIV treatment programme between 2010 and 2014 and discuss implications for CD4 count monitoring. Methods Retrospective analysis of routinely collected laboratory data from South Africa’s National Health Laboratory Service (NHLS). A probabilistic record linkage algorithm was used to create a cohort of HIV positive individuals who initiated ART between 2010 and 2014 based on timing of CD4 count and viral load measurements. A CD4 count < 50 copies/μl at ART initiation was considered severe immunosuppression. A multivariable piecewise mixed-effects linear regression model adjusting for age, gender, year of starting ART, viral suppression in follow up and province was used to predict CD4 counts during follow up. Results 1,070,900 individuals had evidence of starting ART during 2010–2014 and met the criteria for inclusion in the cohort -46.6% starting ART with CD4 < 200 cells/μl and 10.1% with CD4 < 50 cells/ μl. For individuals with CD4 counts < 200 cells/μl, predicted CD4 counts > 200 cells/μl, >350 cells/μl and >500 cells/μl corresponded with mean follow up durations of 1.5 years (standard deviation [s.d] 1.1), 1.9years (s.d 1.2) and 2.1 years (s.d 1.3 years). For those with CD4 counts < 50 cells/μl, predicted CD4 count above these threshold corresponded with mean follow up durations of 2.5 years (s.d 0.9 years), 4.4 years (s.d 0.4 years) and 5.0 years (s.d 0.1years) for recovery to the same thresholds. CD4 count recovery varied mostly with duration on ART, CD4 count at the start of ART and gender. Conclusion For individuals starting with ART with severe immunosuppression, CD4 recovery to 200cells/μl did not occur or took longer than 12 month for significant proportions. CD4 monitoring and interventions recommended for advanced HIV disease should continue until full recovery.
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Stirrup OT, Copas AJ, Phillips AN, Gill MJ, Geskus RB, Touloumi G, Young J, Bucher HC, Babiker AG. Predictors of CD4 cell recovery following initiation of antiretroviral therapy among HIV-1 positive patients with well-estimated dates of seroconversion. HIV Med 2018; 19:184-194. [PMID: 29230953 PMCID: PMC5836945 DOI: 10.1111/hiv.12567] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To investigate factors that predict speed of recovery and long-term CD4 cell count in HIV-1 seroconverters initiating combination antiretroviral therapy (cART), and to quantify the influence of very early treatment initiation. We make use of all pre-treatment CD4 counts, because analyses using only a single observation at initiation may be subject to biases. METHODS We used data from the CASCADE (Concerted Action on SeroConversion to AIDS and Death in Europe) multinational cohort collaboration of HIV-1 seroconverters. We analysed pre- and post-treatment data of patients with seroconversion dates estimated January 2003-March 2014 (n = 7600 for primary analysis) using a statistical model in which the characteristics of recovery in CD4 counts are determined by multiple predictive factors. Secondary analyses were performed incorporating uncertainty in the exact timing of seroconversion to allow more precise estimation of the benefit of very early treatment initiation. RESULTS 'True' CD4 count at cART initiation was the strongest predictor of CD4 count beyond 3 years on cART. Allowing for lack of complete certainty in the date of seroconversion, CD4 recovery was more rapid for patients in whom treatment was initiated within 4 months. For a given CD4 count, higher viral load (VL) at initiation was strongly associated with higher post-treatment CD4 recovery. For other patient and drug characteristics, associations with recovery were statistically significant but small in magnitude. CONCLUSIONS CD4 count at cART initiation is the most important factor in predicting post-treatment recovery, but VL provides substantial additional information. If cART is initiated in the first 4 months following seroconversion, recovery of CD4 counts appears to be more rapid.
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Affiliation(s)
- OT Stirrup
- MRC Clinical Trials UnitUniversity College LondonLondonUK
| | - AJ Copas
- MRC Clinical Trials UnitUniversity College LondonLondonUK
| | - AN Phillips
- Research Department of Infection & Population HealthUniversity College LondonLondonUK
| | - MJ Gill
- Department of MedicineUniversity of CalgaryCalgaryABCanada
| | - RB Geskus
- Department of Clinical Epidemiology, Biostatistics and BioinformaticsAcademic Medical Center (AMC)AmsterdamThe Netherlands
- Department of Infectious DiseasesPublic Health Service of AmsterdamAmsterdamThe Netherlands
- Oxford University Clinical Research UnitWellcome Trust Major Overseas ProgrammeHo Chi Minh CityVietnam
- Nuffield Department of Clinical MedicineCentre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
| | - G Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Medical SchoolNational and Kapodistrian University of AthensAthensGreece
| | - J Young
- Basel Institute for Clinical Epidemiology and BiostatisticsUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - HC Bucher
- Basel Institute for Clinical Epidemiology and BiostatisticsUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - AG Babiker
- MRC Clinical Trials UnitUniversity College LondonLondonUK
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Jain V, Chang W, Byonanebye DM, Owaraganise A, Twinomuhwezi E, Amanyire G, Black D, Marseille E, Kamya MR, Havlir DV, Kahn JG. Estimated Costs for Delivery of HIV Antiretroviral Therapy to Individuals with CD4+ T-Cell Counts >350 cells/uL in Rural Uganda. PLoS One 2015; 10:e0143433. [PMID: 26632823 PMCID: PMC4669141 DOI: 10.1371/journal.pone.0143433] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/04/2015] [Indexed: 12/22/2022] Open
Abstract
Background Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up. Methods Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing. Findings Among 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451–716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100–200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals. Conclusions In a Ugandan HIV clinic, ART delivery costs—including VL testing—for individuals with CD4>350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.
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Affiliation(s)
- Vivek Jain
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- * E-mail:
| | - Wei Chang
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
| | | | | | - Ellon Twinomuhwezi
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Gideon Amanyire
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Douglas Black
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Elliot Marseille
- Health Strategies International, Oakland, CA, United States of America
| | - Moses R. Kamya
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - James G. Kahn
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
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