Scientific Letter

CD4 testing after initiation of antiretroviral therapy: Analysis of routine data from the South African HIV programme

Rivka R. Lilian, Natasha Davies, Louise Gilbert, James A. McIntyre, Helen E. Struthers, Kate Rees
Southern African Journal of HIV Medicine | Vol 21, No 1 | a1165 | DOI: https://doi.org/10.4102/sajhivmed.v21i1.1165 | © 2020 Rivka R. Lilian, Natasha Davies, Louise Gilbert, James A. McIntyre, Helen E. Struthers, Kate Rees | This work is licensed under CC Attribution 4.0
Submitted: 04 September 2020 | Published: 14 December 2020

About the author(s)

Rivka R. Lilian, Anova Health Institute, Johannesburg, South Africa
Natasha Davies, Anova Health Institute, Johannesburg, South Africa
Louise Gilbert, Anova Health Institute, Johannesburg, South Africa
James A. McIntyre, Anova Health Institute, Johannesburg, South Africa; and, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
Helen E. Struthers, Anova Health Institute, Johannesburg, South Africa; and, Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
Kate Rees, Anova Health Institute, Johannesburg, South Africa; and, Department of Community Health, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa


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Abstract

Background: People living with HIV (PLHIV) who have low CD4 counts require advanced clinical care (ACC) to minimise morbidity and mortality risk. These patients include immunological non-responders (INRs) with low CD4 counts despite a suppressed viral load.

Objectives: To determine the proportion of patients with low CD4 counts after antiretroviral therapy (ART) initiation and to describe INRs within that group.

Methods: Routine Three Interlinked Electronic Registers.Net (TIER.Net) data from four South African districts were analysed for adult PLHIV on ART > 12 months. Immunological non-responders were defined as patients on ART > 4 years who were virally suppressed (viral load < 1000 copies/mL) with a CD4 count ≤ 350 cell/mm3.

Results: Baseline CD4 was recorded for 80.9% of the 869 571 patients newly initiating ART, with 37.2% of those starting ART since 2017 having baseline counts ≤ 200 cells/mm3. Amongst all 1 178 190 patients on ART, only 46.5% had a CD4 test after ART initiation and of these, 14.3% had CD4 ≤ 200 cells/mm3. This proportion was highest amongst patients on ART ≤ 2 years (19.7%) (p < 0.001). Amongst virally suppressed patients, 20.0% were INRs. Immunological non-response was significantly more likely amongst patients on second-line ART (adjusted odds ratio [aOR] 1.79), those aged 35-45 and ≥ 45 years (aOR 1.15 and 1.50, respectively), males (aOR 2.28) and patients with confirmed TB (aOR 2.49), and was significantly less likely in cases with higher baseline CD4 count (aOR 0.35).

Conclusion: CD4 testing subsequent to ART initiation is poorly implemented and there is a notable proportion of patients with low CD4 counts. Guidelines regarding CD4 testing and ACC need to be more widely implemented to identify patients with low CD4 counts and improve their outcomes.


Keywords

CD4; HIV; South Africa; advanced clinical care; immunological non-responder; TIER.Net

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