Baseline CD4 and mortality trends in the South African human immunodeficiency virus programme: Analysis of routine data

Abstract

Background Despite widespread availability of antiretroviral therapy (ART) in South Africa, there remains a considerable burden of human immunodeficiency virus (HIV)-related morbidity and mortality. Objectives To describe ART initiation and outcome trends over time, with a focus on clients presenting with advanced HIV-infection, so as to identify interventions to reduce morbidity and mortality. Methods Routine TIER.Net data from HIV-infected adults who had a documented baseline CD4 count and were newly initiating ART in Johannesburg or Mopani districts from 2004 to 2017 were analysed. Trends in baseline CD4 count and 5-year mortality were investigated and the population initiating ART with CD4 < 200 cells/mm 3 was described. Results The Johannesburg and Mopani data sets comprised 203 131 and 101 814 records, respectively. Although median CD4 count increased over time, the proportion of initiations at CD4 < 200 cells/mm 3 in 2017 remained high (Johannesburg 39%, Mopani 35%). Mortality was significantly increased among clients with CD4 < 200 compared to those with higher baseline counts ( p < 0.001). Even though mortality among clients with low CD4 declined over time, likely because of improved drug regimens, in 2016–2017 mortality was still significantly increased among these clients ( p < 0.001). Delivery of cotrimoxazole prophylaxis to clients with low CD4 declined over time to < 30% in 2017 and was associated with clinical stage. Presentation with CD4 < 200 cells/mm 3 was associated with older age, male gender and hospitalisation. Conclusion A concerningly large proportion of South Africans still initiate ART at low CD4 counts. This is associated with increased mortality and requires targeted interventions to improve delivery of prophylactic regimens and early engagement in care.

Recent HIV infection among pregnant women in the 2017 antenatal sentinel cross–sectional survey, South Africa: Assay–based incidence measurement

“…Prior to the introduction of test–and–treat, this algorithm worked well for estimating incidence as the guideline at the time recommended delayed ART initiation. While the scale up of test and treat has been a major breakthrough and an important intervention globally, as the number of individuals who initiate ART in the early stage of their infection increases with the scale up of test and treat, clinical criteria such as viral load and ART can no longer accurately differentiate recent infections from long–term infections [ 41 , 42 ]. The PMTCT programme, in particular, has high ART coverage [ 43 , 44 ].…”

Understanding the Reasons for Deferring ART Among Patients Diagnosed Under the Same-Day-ART Policy in Johannesburg, South Africa

“…Previous studies reported a 20% ART deferral rate among ART eligible patients diagnosed under the CD4 < 350 policy [ 21 ]. Although the proportion of participants diagnosed with CD4 > 350 was marginally higher during the SDI policy than under previous ART guidelines; the majority still test at CD4 counts below 350 cell/µl [ 42 ]. The reduced dependence on CD4 test results for ART initiation under the UTT and SDI policies may have inadvertently resulted in a reduced availability of baseline CD4 results, as nearly half of the participants were missing baseline CD4 data in their clinic files [ 37 ].…”

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

“…It is concerning that low baseline CD4 is significantly associated with immunological non-response, as a notable proportion of patients initiating ART in South Africa do so with low CD4 counts. 2 In particular, older patients and males are more likely to present late for HIV care with low baseline CD4, 2 which may contribute to the poor CD4 recovery of these patients. Continued engagement with communities, particularly with men and older clients, is required to emphasise the importance of engaging with ART services before CD4 counts have dropped substantially.…”

“…1 Advanced clinical care is particularly important in South Africa, considering that up to 40% of adults initiate ART with CD4 < 200 cells/mm 3 . 2 Furthermore, up to 50% of patients receiving ART demonstrate poor CD4 recovery, dependant on multiple factors including baseline CD4 count and CD4 recovery definition. 3 , 4 , 5 , 6 In some patients, known as immunological non-responders (INRs), CD4 count remains low despite a suppressed VL, which significantly increases the risk of mortality.…”