Mortality, AIDS-morbidity, and loss to follow-up by current CD4 cell count among HIV-1-infected adults receiving antiretroviral therapy in Africa and Asia: data from the ANRS 12222 collaboration

Abstract

Background: In resource-limited countries, estimating CD4-specific incidence rates of mortality and morbidity among patients receiving antiretroviral therapy (ART) may help assess the effectiveness of care and treatment programmes, identify program weaknesses, and inform decisions.

Methods: We pooled data from 13 research cohorts in 5 sub-Saharan African (Benin, Burkina Faso, Cameroon, Cote d'Ivoire, and Senegal) and 2 Asian (Cambodia and Laos) countries. HIV-infected adults (18 years and older) who received ART in 1998-2008 and had at least one CD4 count available were eligible. Changes in CD4 counts over time were estimated by a linear mixed regression. CD4-specific incidence rates were estimated as the number of first events occurring in a given CD4 stratum divided by the time spent within the stratum.

Results: Overall 3917 adults (62% women) on ART were followed up during 10,154 person-years. In the ≤ 50, 51-100, 101-200, 201-350, 351-500, 501-650, and >650 cells/mm CD4 cells strata, death rates were 20.6, 11.8, 6.7, 3.3, 1.8, 0.9, and 0.3 per 100 person-years; AIDS rates were 50.5, 32.9, 11.5, 4.8, 2.8, 2.2, and 2.2 per 100 person-years; and loss-to-follow-up rates were 4.9, 6.1, 3.5, 3.1, 2.9, 1.7, and 1.2 per 100 person-years, respectively. Mortality and morbidity were higher during the first year after ART initiation.

Conclusions: In these resource-limited settings, death and AIDS rates remained substantial after ART initiation, even in individuals with high CD4 cell counts. Ensuring earlier ART initiation and optimizing case finding and treatment for AIDS-defining diseases should be seen as priorities.

Figure 1

Mean increase in CD4 cell count ⁽¹⁾ among HIV-infected patients receiving ART in Africa and Asia by baseline value, ANRS 12222 Morbidity/Mortality Collaboration. Footnotes for Figure 1 : (1) CD4 modelized adjusted on covariates (cohort, gender, baseline age, baseline CD4 cell count, baseline WHO clinical stage, and year of ART initiation) (2) Mean CD4 increase at 3 months (3) Mean CD4 increase at 2 years (4) Mean CD4 increase at 4 years

Figure 2

Figure 2 A. Mortality and morbidity incidence rates among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count, ANRS 12222 Morbidity/Mortality Collaboration. Figure 2 B. Mortality and morbidity incidence rates among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count (focus on CD4 above 200/mm³), ANRS 12222 Morbidity/Mortality Collaboration.

Figure 2

Figure 2 A. Mortality and morbidity incidence rates among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count, ANRS 12222 Morbidity/Mortality Collaboration. Figure 2 B. Mortality and morbidity incidence rates among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count (focus on CD4 above 200/mm³), ANRS 12222 Morbidity/Mortality Collaboration.

Figure 3

Figure 3 A. Mortality incidence rates during the first year and thereafter among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count, ANRS 12222 Morbidity/Mortality Collaboration. Figure 3 B. AIDS incidence rates during the first year and thereafter among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count, ANRS 12222 Morbidity/Mortality Collaboration.

Figure 3

Figure 3 A. Mortality incidence rates during the first year and thereafter among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count, ANRS 12222 Morbidity/Mortality Collaboration. Figure 3 B. AIDS incidence rates during the first year and thereafter among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count, ANRS 12222 Morbidity/Mortality Collaboration.

Figure 4

Loss to follow-up incidence rates during the first year, thereafter and overall among HIV-infected patients receiving ART in Africa and Asia by current CD4 cell count, ANRS 12222 Morbidity/Mortality Collaboration.