Factors Associated with Timing of Initiation of Antiretroviral Therapy among HIV-1 Infected Adults in the Niger Delta Region of Nigeria

Abstract

Introduction: Based on growing evidence mainly from countries outside Sub-Saharan Africa, the World Health Organisation (WHO) now recommends initiation of antiretroviral therapy (ART) in HIV-infected individuals in developing countries when CD4 cell count (CD4+) is ≤ 500 cells/ul. Nigeria accounts for about 14% of the estimated HIV/AIDS burden in Sub-Saharan Africa. We evaluated the factors associated with timing of initiation of ART among treatment-ineligible HIV-infected adults from Nigeria.

Methods: We retrospectively reviewed the hospital records of ART ineligible HIV-infected adults who enrolled into HIV care between January 2008 and December 2012 at two major tertiary hospitals in Bayelsa State, South-South Nigeria. Demographic, clinical and laboratories data were obtained at presentation, at each subsequent visit at 6 monthly intervals and at time of initiation of ART. Cox proportional regression and Kaplan-Meier survival analysis were used to evaluate independent predictors of time to initiation of ART.

Results: Amongst the 280 study participants, 70.6% were females, 62.6% had CD4+ ≥500 cells/ul, 48.4% had WHO HIV Stage 1 disease and 34.3% were lost to follow up. In a cohort of 180 participants followed up for ≥3 months, participants with CD4+ of 351-500 cells/ul and stage 2 disease were more likely to start ART earlier than those with CD4+ > 500 cells/ul (Hazard ratio [HR]-1.7, 95% confidence interval [CI] of 1.0-2.9) and stage 1 disease (HR-2.3 (95% CI-1.3-4.2) respectively. HIV-infected adults with faster CD4+ decay required earlier ART initiation, especially in the first year of follow up.

Conclusion: ART-ineligible HIV-infected adults on follow up in South-South Nigeria are more likely to require earlier initiation of ART if they have stage 2 HIV disease or CD4+ ≤500 cells/ul at presentation. Our findings suggest faster progression of HIV-disease in these groups of individuals and corroborate the growing evidence in support for earlier initiation of ART.

Fig 1. Kaplan-Meier curves of time to initiation of ART in relation to CD4 cell count group.

The median time to ART initiation was significantly shorter in participants with CD4 cell count of 351-500cells/ul than those (16months) with CD4 count >500cells/ul (23months).

Fig 2. Kaplan-Meier curves of time to initiation of ART in relation to WHO HIV stage.

The median time to ART initiation was significantly shorter in participants with stage 2 disease (15months) than participants with stage 1 disease (23months).

Fig 3. Temporal 6monthly median CD4 cell counts according to ART status.

At each individual time points, the observed median CD4 cell counts were significantly higher in participants who were yet to start ART (p<0.0001 at each indivudal time points of 0, 6, 12 and 24 months and p = 0.0001 at 18months; Mann Whitnet test). Among study participants who started ART, the graph shows a steep and progressive drop in median CD4 cell counts in the first year of follow up.