1
|
Leeme TB, Mine M, Lechiile K, Mulenga F, Mosepele M, Mphoyakgosi T, Muthoga C, Ngidi J, Nkomo B, Ramaabya D, Tau M, Tenforde MW, Hayes R, Jarvis JN. Utility of CD4 count measurement in the era of universal antiretroviral therapy: an analysis of routine laboratory data in Botswana. HIV Med 2020; 22:1-10. [PMID: 32876378 DOI: 10.1111/hiv.12951] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES National guidelines in Botswana recommend baseline CD4 count measurement and both CD4 and HIV viral load (VL) monitoring post-antiretroviral therapy (ART) initiation. We evaluated the utility of CD4 count measurement in Botswana in the era of universal ART. METHODS CD4 and VL data were analysed for HIV-infected adults undergoing CD4 count measurement in 2015-2017 at the Botswana Harvard HIV-Reference Laboratory. We determined (1) the proportion of individuals with advanced HIV disease (CD4 count < 200 cells/µL) at initial CD4 assessment, (2) the proportion with an initial CD4 count ≥ 200 cells/µL experiencing a subsequent decline in CD4 count to < 200 cells/µL, and (3) the proportion of these immunologically failing individuals who had virological failure. Logistic regression modelling examined factors associated with advanced HIV disease. CD4 count trajectories were assessed using locally weighted scatterplot smoothing (LOWESS) regression. RESULTS Twenty-five per cent (3571/14 423) of individuals with an initial CD4 assessment during the study period had advanced HIV disease at baseline. Older age [≥ 35 years; adjusted odds ratio (aOR) 1.9; 95% confidence interval (CI) 1.8-2.1] and male sex were associated with advanced HIV disease. Fifty per cent (7163/14 423) of individuals had at least two CD4 counts during the study period. Of those with an initial CD4 count ≥ 200 cells/µL, 4% (180/5061) experienced a decline in CD4 count to < 200 cells/µL; the majority of CD4 count declines were in virologically suppressed individuals and transient. CONCLUSIONS One-quarter of HIV-positive individuals in Botswana still present with advanced HIV disease, highlighting the importance of baseline CD4 count measurement to identify this at-risk population. Few with a baseline CD4 count ≥ 200 cells/µL experienced a drop below 200 cells/µL, suggesting limited utility for ongoing CD4 monitoring.
Collapse
Affiliation(s)
- T B Leeme
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - M Mine
- National Health Laboratory, Gaborone, Botswana
| | - K Lechiile
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - F Mulenga
- National Health Laboratory, Gaborone, Botswana
| | - M Mosepele
- Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | - C Muthoga
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Botswana-UPenn Partnership, Gaborone
| | - J Ngidi
- National Health Laboratory, Gaborone, Botswana
| | - B Nkomo
- Ministry of Health and Wellness, Gaborone, Botswana
| | - D Ramaabya
- Ministry of Health and Wellness, Gaborone, Botswana
| | - M Tau
- Ministry of Health and Wellness, Gaborone, Botswana
| | | | - R Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - J N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
2
|
Chow EPF, Phillips TR, Bradshaw CS, Chen MY, Fairley CK. Brief Report: Sexual Mixing Patterns by HIV Status and PrEP Use Among Men Who Have Sex With Men Partnerships in Melbourne, 2011-2018. J Acquir Immune Defic Syndr 2020; 83:99-102. [PMID: 31929399 DOI: 10.1097/qai.0000000000002231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sexual mixing between HIV-positive, HIV-negative, and pre-exposure prophylaxis (PrEP) users among men who have sex with men (MSM) is an important determinant of the incidence of infection. There have been very limited studies examining the patterns of sexual mixing in relation to HIV status and PrEP use in the era of PrEP. SETTING Melbourne Sexual Health Centre (MSHC), Australia. METHODS We included all MSM partnerships attending MSHC on the same day between 2011 and 2018. A chi-square trend test was used to examine the changes in the annual proportion of partnerships by HIV serostatus in 2011-2018 and by PrEP use in 2016-2018. RESULTS Of the 1765 MSM partnerships who attended MSHC between 2011 and 2018, 1.3% of the partnerships were concordant HIV-positive, 91.0% were concordant HIV-negative, and 7.6% were HIV-discordant. The proportion of HIV-discordant partnerships increased from 0% in 2011 to 12.5% in 2018 (ptrend < 0.001). In 2016-2018, only a small proportion (1.2%) of concordant HIV-negative partnerships involved both men taking PrEP, whereas 6.0% involved at least one man taking PrEP. Overall, 79.1% of concordant HIV-negative partnerships were not protected against HIV (ie, neither man taking PrEP), and this proportion declined significantly from 84.3% in 2016 to 74.0% in 2018 (ptrend = 0.001). CONCLUSIONS The pattern of sexual mixing by HIV status and PrEP use among MSM partnerships has changed over time. PrEP use in both men within MSM partnerships is not common. About 79% of concordant HIV-negative partnerships were not protected against HIV as neither man taking PrEP.
Collapse
Affiliation(s)
- Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; and.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Tiffany R Phillips
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; and.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Catriona S Bradshaw
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; and.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Marcus Y Chen
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; and.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia; and.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Johnson SM, Standing JF, Klein N, Irwin AD, Shingadia D, Lonsdale DO, Gilmour KC, Flynn J, Manns C, Clapson M, Bamford A. A case for reduced frequency of CD4 count monitoring for children on combination antiretroviral therapy with consistently undetectable HIV viral load. HIV Med 2019; 20:e8-e9. [PMID: 30693658 DOI: 10.1111/hiv.12706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S M Johnson
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - J F Standing
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - N Klein
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - A D Irwin
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
| | - D Shingadia
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - D O Lonsdale
- Institute of Infection and Immunity, St George's University and St George's Hospital, London, UK
| | - K C Gilmour
- UCL Great Ormond Street Institute of Child Health, London, UK.,Department of Immunology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - J Flynn
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - C Manns
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - M Clapson
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - A Bamford
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| |
Collapse
|
4
|
Chow EPF, Callander D, Fairley CK, Zhang L, Donovan B, Guy R, Lewis DA, Hellard M, Read P, Ward A, Chen MY. Increased Syphilis Testing of Men Who Have Sex With Men: Greater Detection of Asymptomatic Early Syphilis and Relative Reduction in Secondary Syphilis. Clin Infect Dis 2018; 65:389-395. [PMID: 28419198 DOI: 10.1093/cid/cix326] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/12/2017] [Indexed: 11/14/2022] Open
Abstract
Background Syphilis rates have increased markedly among men who have sex with men (MSM) internationally. We examined trends in syphilis testing and detection of early syphilis among MSM in Australia. Methods Serial cross-sectional analyses on syphilis testing and diagnoses among MSM attending a national sentinel network of 46 clinics in Australia between 2007 and 2014. Results 359313 clinic visits were included. The proportion of MSM serologically tested for syphilis annually increased in HIV-negative (48% to 91%; Ptrend < .0001) and HIV-positive MSM (42% to 77%; Ptrend < .0001). The mean number of tests per man per year increased from 1.3 to 1.6 in HIV-negative MSM (Ptrend < .0001) and from 1.6 to 2.3 in HIV-positive MSM (Ptrend < .0001). 2799 and 1032 syphilis cases were detected in HIV-negative and HIV-positive MSM, respectively. Among HIV-negative MSM, the proportion of infections that were early latent increased from 27% to 44% (Ptrend < .0001), while the proportion that were secondary decreased from 24% to 19% (Ptrend = .030). Among HIV-positive MSM, early latent infections increased from 23% to 45% (Ptrend < .0001), while secondary infections decreased from 45% to 26% (Ptrend = .0003). Among HIV-positive MSM, decreasing secondary syphilis correlated with increasing testing coverage (r = -0.87; P = .005) or frequency (r = -0.93; P = .001). Conclusions Increases in syphilis screening were associated with increased detection of asymptomatic infectious syphilis and relative falls in secondary syphilis for both HIV-positive and HIV-negative MSM nationally, suggesting interruption of syphilis progression.
Collapse
Affiliation(s)
- Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria
| | - Denton Callander
- The Kirby Institute.,Centre for Social Research in Health, UNSW Sydney
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria
| | - Lei Zhang
- Melbourne Sexual Health Centre, Alfred Health.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria
| | - Basil Donovan
- The Kirby Institute.,Sydney Sexual Health Centre, Sydney Hospital
| | | | - David A Lewis
- Western Sydney Sexual Health Centre, Parramatta.,Marie Bashir Institute for Infectious Diseases and Biosecurity & Sydney Medical School-Westmead, University of Sydney, New South Wales
| | - Margaret Hellard
- Burnet Institute.,Infectious Disease Unit, Alfred Hospital, Melbourne, Victoria
| | - Phillip Read
- The Kirby Institute.,Kirketon Road Centre, Kings Cross, Sydney, New South Wales
| | - Alison Ward
- Clinic 275, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Marcus Y Chen
- Melbourne Sexual Health Centre, Alfred Health.,Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria
| | | |
Collapse
|
5
|
Di Biagio A, Ameri M, Sirello D, Cenderello G, Di Bella E, Taramasso L, Giannini B, Giacomini M, Viscoli C, Cassola G, Montefiori M. Is it still worthwhile to perform quarterly cd4+ t lymphocyte cell counts on hiv-1 infected stable patients? BMC Infect Dis 2017; 17:127. [PMID: 28166729 PMCID: PMC5294769 DOI: 10.1186/s12879-017-2199-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 01/10/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In the last 20 years routine T CD4+ lymphocyte (CD4+) cell count has proved to be a key factor to determine the stage of HIV infection and start or discontinue of prophylaxis for opportunistic infections. However, several studies recently showed that in stable patients on cART a quarterly CD4+ cell count monitoring results in limited (or null) clinical relevance. The research is intended to investigate whether performing quarterly CD4+ cell counts in stable HIV-1 patients is still recommendable and to provide a forecast of the cost saving that could be achieved by reducing CD4+ monitoring in such a category of patients. METHODS The study is based on data referring to all HIV-infected patients > 18 years of age being treated at two large infectious diseases units located in the metropolitan area of Genoa, Italy. The probability of CD4+ cell counts dropping below a threshold value set at 350 cells/mm3 is assessed using confidence intervals and Kaplan-Meier survival estimates, whereas multivariate Cox analysis and logistic regression are implemented in order to identify factors associated with CD4+ cell count falls below 350 cells/mm3. RESULTS Statistical analysis reveals that among stable patients the probability of maintaining CD4+ >350 cell/mm3 is more than 98%. Econometric models indicate that HCV co-infection and HIV-RNA values >50 copies/mL in previous examinations are associated with CD4+ falls below 350 cells/mm3. Moreover, results suggest that the cost saving that could be obtained by reducing CD4+ examinations ranges from 33 to 67%. CONCLUSIONS Empirical findings shows that patients defined as stable at enrollment are highly unlikely to experience a CD4+ value <350 cell/mm3 in the space/arc of a year. The research supports a recommendation for annual CD4+ monitoring in stable HIV-1 patients.
Collapse
Affiliation(s)
- Antonio Di Biagio
- Infectious Disease Clinic, IRCCS San Martino - IST Hospital, Genoa, Italy
| | - Marta Ameri
- Department of Economics, University of Genoa, Via Vivaldi 5, 16126, Genoa, Italy.
| | - Davide Sirello
- Infectious Disease Clinic, IRCCS San Martino - IST Hospital, Genoa, Italy
| | | | - Enrico Di Bella
- Department of Economics, University of Genoa, Via Vivaldi 5, 16126, Genoa, Italy
| | - Lucia Taramasso
- Infectious Disease Clinic, IRCCS San Martino - IST Hospital, Genoa, Italy
| | - Barbara Giannini
- Department of Informatics, Bioengineering, Robotics and System Engineering, University of Genoa, Genoa, Italy
| | - Mauro Giacomini
- Department of Informatics, Bioengineering, Robotics and System Engineering, University of Genoa, Genoa, Italy
| | - Claudio Viscoli
- Infectious Disease Clinic, IRCCS San Martino - IST Hospital, Genoa, Italy
| | | | - Marcello Montefiori
- Department of Economics, University of Genoa, Via Vivaldi 5, 16126, Genoa, Italy
| |
Collapse
|
6
|
Nakanjako D, Kiragga AN, Musick BS, Yiannoutsos CT, Wools-Kaloustian K, Diero L, Oyaro P, Lugina E, Ssali JC, Kambugu A, Easterbrook P. Frequency and impact of suboptimal immune recovery on first-line antiretroviral therapy within the International Epidemiologic Databases to Evaluate AIDS in East Africa. AIDS 2016; 30:1913-22. [PMID: 26959510 PMCID: PMC5438045 DOI: 10.1097/qad.0000000000001085] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To describe patterns of suboptimal immune recovery (SO-IR) and associated HIV-related-illnesses during the first 5 years following first-line antiretroviral therapy (ART) initiation across seven ART sites in East Africa. DESIGN Retrospective analysis of data from seven ART clinical sites (three Uganda, two Kenya and two Tanzania). METHODS SO-IR was described by proportions of ART-treated adults with CD4 cell counts less than 200, less than 350 and less than 500 cells/μl. Kaplan-Meier survival analysis techniques were used to assess predictors of SO-IR, and incident rates of HIV-related illnesses at CD4 cell counts less than 200, 200-350, 351-499, and >500 cells/μl, respectively. RESULTS Overall 80 843 adults initiated non-nucleoside reverse transcriptase inhibitor-based first-line ART; 65% were women and median CD4 cell count was 126 [interquartile range (IQR), 52-202] cells/μl. Cumulative probability of SO-IR <200 cells/μl, <350 cells/μl and <500 cells/μl, after 5 years, was 11, 38 and 63%, respectively. Incidence of HIV-related illnesses was higher among those with CD4 cell counts less than 200 and 200-350 cells/μl, than those who achieved CD4 counts above these thresholds. The most common events, at CD4 < 200 cells/μl, were pulmonary tuberculosis [incident rate 15.98 (15.47-16.51)/100 person-years at risk (PYAR), oral candidiasis [incident rate 12.5 (12.03-12.94)] and herpes zoster [incident rate 6.30 (5.99-6.64)] events/100 PYAR. With attainment of a CD4 cell count level 200-350 cells/μl, there was a substantial reduction in events/100 PYAR - by 91% to 1.45 (1.29-1.63) for TB, by 94% to 0.75 (0.64-0.89) for oral candidiasis, by 84% to 0.99 (0.86-1.14) for Herpes Zoster, and by 78% to 1.22 (1.07-1.39) for chronic diarrhea. The incidence of all events decreased further with CD4 counts above these thresholds. CONCLUSION Around 40% of adults initiated on ART have suboptimal immune recovery with CD4 counts <350 cells/μl after five years. Such patients will require closer monitoring for both HIV-related and non-HIV-related clinical events.
Collapse
Affiliation(s)
- Damalie Nakanjako
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Agnes N. Kiragga
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Beverly S. Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Constantin T. Yiannoutsos
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biostatistics, Indiana University, RM Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Kara Wools-Kaloustian
- Department of Medicine at Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lameck Diero
- Academic Model Providing Access to Healthcare, Eldoret, kenya
| | - Patrick Oyaro
- Family AIDS, Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Emanuel Lugina
- Ocean Road Cancer Institute, Dar es salaam, Tanzania, Kisumu
| | - John C. Ssali
- HIV Treatment Program, Masaka Regional Referral Hospital, Masaka, Uganda
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Philippa Easterbrook
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
7
|
Implementation and Operational Research: CD4 Count Monitoring Frequency and Risk of CD4 Count Dropping Below 200 Cells Per Cubic Millimeter Among Stable HIV-Infected Patients in New York City, 2007-2013. J Acquir Immune Defic Syndr 2016; 71:e73-8. [PMID: 26536317 PMCID: PMC4770377 DOI: 10.1097/qai.0000000000000885] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Introduction: The evidence has begun to mount for diminishing the frequency of CD4 count testing. To determine whether these observations were applicable to an urban US population, we used New York City (NYC) surveillance data to explore CD4 testing among stable patients in NYC, 2007–2013. Methods: We constructed a population-based retrospective open cohort analysis of NYC HIV surveillance data. HIV+ patients aged ≥13 years with stable viral suppression (≥1 viral load the previous year; all <400 copies per milliliter) and immune status (≥1 CD4 the previous year; all ≥200 cells per cubic millimeter) entered the cohort the following year beginning January 1, 2007. Each subsequent year, eligible patients not previously included entered the cohort on January 1. Outcomes were annual frequency of CD4 monitoring and probability of maintaining CD4 ≥200 cells per cubic millimeter. A multivariable Cox model identified factors associated with maintaining CD4 ≥200 cells per cubic millimeter. Results: During 1.9 years of observation (median), 62,039 patients entered the cohort. The mean annual number of CD4 measurements among stable patients was 2.8 and varied little by year or characteristic. Two years after entering, 93.4% and 97.8% of those with initial CD4 350–499 and CD4 ≥500 cells per cubic millimeter, respectively, maintained CD4 ≥200 cells per cubic millimeter. Compared to those with initial CD4 ≥500 cells per cubic millimeter, those with CD4 200–349 cells per cubic millimeter and CD4 350–499 cells per cubic millimeter were more likely to have a CD4 <200 cells per cubic millimeter, controlling for sex, race, age, HIV risk group, and diagnosis year. Conclusions: In a population-based US cohort with well-controlled HIV, the probability of maintaining CD4 ≥200 cells per cubic millimeter for ≥2 years was >90% among those with initial CD4 ≥350 cells per cubic millimeter, suggesting that limited CD4 monitoring in these patients is appropriate.
Collapse
|
8
|
Nicolás D, Esteve A, Cuadros A, Campbell CNJ, Tural C, Podzamczer D, Murillas J, Homar F, Segura F, Force L, Vilaró J, Masabeu À, Garcia I, Mercadal J, Montoliu A, Ferrer E, Riera M, Cifuentes C, Ambrosioni J, Navarro G, Manzardo C, Clotet B, Gatell JM, Casabona J, Miró JM, Murillas J, Manzardo C, Masabeu A, Mercadal J, Cifuentes C, Dalmau D, Domingo P, Falcó V, Curran A, Agustí C, Montoliu A, Pérez I, Curto J, Gargoulas F, Gómez A, Rubia JC, Zamora L, Blanco JL, Garcia-Alcaide F, Martínez E, Mallolas J, Llibre JM, Sirera G, Romeu J, Jou A, Negredo E, Saumoy M, Imaz A, Bolao F, Cabellos C, Peña C, DiYacovo S, Van Den Eynde E, Sala M, Cervantes M, Amengual MJ, Navarro M, Segura V, Barrufet P, Molina J, Alvaro M, Payeras T, Gracia Mateo M, Fernández J. Safe Reduction in CD4 Cell Count Monitoring in Stable, Virally Suppressed Patients With HIV Infection or HIV/Hepatitis C Virus Coinfection. Clin Infect Dis 2016; 62:1578-1585. [PMID: 27126346 DOI: 10.1093/cid/ciw157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/09/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It has been suggested that routine CD4 cell count monitoring in human immunodeficiency virus (HIV)-monoinfected patients with suppressed viral loads and CD4 cell counts >300 cell/μL could be reduced to annual. HIV/hepatitis C virus (HCV) coinfection is frequent, but evidence supporting similar reductions in CD4 cell count monitoring is lacking for this population. We determined whether CD4 cell count monitoring could be reduced in monoinfected and coinfected patients by estimating the probability of maintaining CD4 cell counts ≥200 cells/µL during continuous HIV suppression. METHODS The PISCIS Cohort study included data from 14 539 patients aged ≥16 years from 10 hospitals in Catalonia and 2 in the Balearic Islands (Spain) since January 1998. All patients who had at least one period of 6 months of continuous HIV suppression were included in this analysis. Cumulative probabilities with 95% confidence intervals were calculated using the Kaplan-Meier estimator stratified by the initial CD4 cell count at the period of continuous suppression initiation. RESULTS A total of 8695 patients were included. CD4 cell counts fell to <200 cells/µL in 7.4% patients, and the proportion was lower in patients with an initial count >350 cells/µL (1.8%) and higher in those with an initial count of 200-249 cells/µL (23.1%). CD4 cell counts fell to <200 cells/µL in 5.7% of monoinfected and 11.1% of coinfected patients. Of monoinfected patients with an initial CD4 cell count of 300-349 cells/µL, 95.6% maintained counts ≥200 cells/µL. In the coinfected group with the same initial count, this rate was lower, but 97.6% of coinfected patients with initial counts >350 cells/µL maintained counts ≥200 cells/µL. CONCLUSIONS From our data, it can be inferred that CD4 cell count monitoring can be safely performed annually in HIV-monoinfected patients with CD4 cell counts >300 cells/µL and HIV/HCV-coinfected patients with counts >350 cells/µL.
Collapse
Affiliation(s)
- David Nicolás
- Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona
| | - Anna Esteve
- Centre for Epidemiological Studies on HIV/STI in Catalonia - ASPC, CIBER Epidemiologia y Salud Publica
| | | | - Colin N J Campbell
- Centre for Epidemiological Studies on HIV/STI in Catalonia - ASPC, CIBER Epidemiologia y Salud Publica
| | - Cristina Tural
- Fundació Lluita Contra la Sida, Fundacio Irsicaixa, Hospital Universitari Germans Trias i Pujol
| | - Daniel Podzamczer
- Hospital Universitari de Bellvitge-Bellvitge Institute for Biomedical Research, Hospitalet de Llobregat
| | | | | | - Ferrán Segura
- Corporació Sanitària i Universitària Parc Taulí, Universitat Autónoma de Barcelona
| | | | | | | | | | | | - Alexandra Montoliu
- Centre for Epidemiological Studies on HIV/STI in Catalonia - ASPC, CIBER Epidemiologia y Salud Publica
| | - Elena Ferrer
- Hospital Universitari de Bellvitge-Bellvitge Institute for Biomedical Research, Hospitalet de Llobregat
| | | | | | - Juan Ambrosioni
- Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona
| | - Gemma Navarro
- Corporació Sanitària i Universitària Parc Taulí, Universitat Autónoma de Barcelona
| | - Christian Manzardo
- Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona
| | - Bonaventura Clotet
- Hospital Universitari de Bellvitge-Bellvitge Institute for Biomedical Research, Hospitalet de Llobregat
| | - Josep M Gatell
- Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona
| | - Jordi Casabona
- Centre for Epidemiological Studies on HIV/STI in Catalonia - ASPC, CIBER Epidemiologia y Salud Publica
| | - José M Miró
- Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Abstract
BACKGROUND Ongoing CD4 monitoring in patients on antiretroviral therapy (ART) with viral suppression has been questioned. We evaluated the probability of CD4 decline in children with viral suppression and CD4 recovery after 1 year on ART. METHODS We included children from 8 South African cohorts with routine HIV-RNA monitoring if (1) they were "responders" [HIV-RNA < 400 copies/mL and no severe immunosuppression after ≥1 year on ART (time 0)] and (2) ≥1 HIV-RNA and CD4 measurement within 15 months of time 0. We determined the probability of CD4 decline to World Health Organization-defined severe immunosuppression for 3 years after time 0 if viral suppression was maintained. Follow-up was censored at the earliest of the following dates: the day before first HIV-RNA measurement >400 copies/mL; day before a >15-month gap in testing and date of death, loss to follow-up, transfer out or database closure. RESULTS Among 5984 children [median age at time 0: 5.8 years (interquartile range: 3.1-9.0)], 270 children experienced a single CD4 decline to severe immunosuppression within 3 years of time 0 with probability of 6.6% (95% CI: 5.8-7.4). A subsequent CD4 measurement within 15 months of the first low measurement was available for 63% of children with CD4 decline and 86% showed CD4 recovery. The probability of CD4 decline was lowest (2.8%) in children aged 2 years or older with no or mild immunosuppression and on ART for <18 months at time 0. This group comprised 40% of children. CONCLUSIONS This finding suggests that it may be safe to stop routine CD4 monitoring in children older than 2 years and rely on virologic monitoring alone.
Collapse
|
10
|
CD4 changes among virologically suppressed patients on antiretroviral therapy: a systematic review and meta-analysis. J Int AIDS Soc 2015; 18:20061. [PMID: 26257204 PMCID: PMC4530137 DOI: 10.7448/ias.18.1.20061] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 06/19/2015] [Accepted: 07/03/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction The effectiveness of antiretroviral therapy (ART) is assessed by measuring CD4 cell counts and viral load. Recent studies have questioned the added value of routine CD4 cell count measures in patients who are virologically suppressed. Methods We systematically searched three databases and two conference sites up to 31 October 2014 for studies reporting CD4 changes among patients who were on ART and virologically suppressed. No geographic, language or age restrictions were applied. Results and discussion We identified 12 published and 1 unpublished study reporting CD4 changes among 20,297 virologically suppressed patients. The pooled proportion of patients who experienced an unexplained, confirmed CD4 decline was 0.4% (95% CI 0.2–0.6%). Results were not influenced by duration of follow-up, age, study design or region of economic development. No studies described clinical adverse events among virologically suppressed patients who experienced CD4 declines. Conclusions The findings of this review support reducing or stopping routine CD4 monitoring for patients who are immunologically stable on ART in settings where routine viral load monitoring is provided.
Collapse
|