Predictors of Poor CD4 and Weight Recovery in HIV-Infected Children Initiating ART in South Africa

Abstract

ObjectiveTo identify baseline demographic and clinical risk factors associated with poor CD4 and weight response after initiation of antiretroviral therapy (ART) in a cohort of human immunodeficiency virus (HIV)-infected children in KwaZulu-Natal, South Africa.MethodsWe performed a retrospective cohort study of 674 children initiating antiretroviral therapy at McCord and St. Mary's hospitals in KwaZulu-Natal, South Africa, from August 2003 to December 2008.We extracted data from paper charts and electronic medical records to assess risk factors associated with CD4 and weight response using logistic regression.ResultsFrom the initial cohort of 901 children <10 years old initiating ART between August 2003 and December 2008, we analyzed 674 children with complete baseline data. Viral suppression rates (<400 copies/ml) were 84% after six months of therapy and 88% after 12 months of therapy. Seventy-three percent of children achieved CD4 recovery after six months and 89% after 12 months. Weight-for-age Z-score (WAZ) improvements were seen in 58% of children after six months of ART and 64% after 12 months. After six months of ART, lower baseline hemoglobin (p = 0.037), presence of chronic diarrhea (p = 0.007), and virologic failure (p = 0.046) were all associated with poor CD4 recovery by multivariate logistic regression. After 12 months of ART, poor CD4 recovery was associated with higher baseline CD4% (p = 0.005), chronic diarrhea (p = 0.02), and virologic failure (p<0.001). Age less than 3 years at ART initiation (p = 0.0003), higher baseline CD4% (p<0.001), and higher baseline WAZ (p<0.001) were all associated with poor WAZ improvements after 6 months by multivariate logistic regression.ConclusionThe presence of chronic diarrhea at baseline, independent of nutritional status and viral response, predicts poor CD4 recovery. Age at initiation of ART is an important factor in early WAZ response to ART, while viral suppression strongly predicts CD4 recovery but not WAZ improvement.

Predictors of Sub-Optimal CD4 Recovery during the First Six Months of Anti-Retroviral Treatment (ART) in HIV Infected Children: A Retrospective Cross Sectional Study from Tikur Anbessa Tertiary Hospital, Addis Ababa, Ethiopia

“…This might be justified by too depleted thymus and other lymphoid tissues to repopulate the T lymphocytes after initiation of ART in older age groups. On the other hand, in our study there is no relationship between gender of the patient and risk of adverse immune restoration though other studies were with discordant results; some reported male gender is associated with poor immune recovery others showed no gender difference [14][15][16]. Presence of chronic diarrhea during ART treatment is associated with poor CD4 cell recovery independent of nutritional status of the patient which is in agreement with most previous studies.…”

Evaluation of treatment outcomes for patients on first‐line regimens in US President's Emergency Plan for AIDS Relief (PEPFAR) clinics in Uganda: predictors of virological and immunological response from RV288 analyses

“…Baseline and nadir CD4 counts are major determinants of CD4 cell recovery after ART initiation [32][33][34][35][36][37][38], so individuals with higher CD4 cell counts starting ART will recover more cells. This has led to African Ministries of Health progressively increasing the target CD4 cell count for when to start antiretrovirals.Age is a well-recognized factor influencing CD4 cell count recovery [39][40][41][42], resulting in the 2012 Department of Health and Human Services (DHHS) guidelines recommending ART for all individuals over 50 years old, irrespective of CD4 cell count.Haemoglobin, a valuable indicator of health status, has been reported to be associated with CD4 cell reconstitution [43] and with survival in HIV-infected individuals [44]. Many studies looked at baseline haemoglobin at the start of therapy, but we found that the increase in haemoglobin from baseline to the time of the study visit was a better indicator of CD4 cell recovery than baseline or study visit haemoglobin levels alone.…”

Tackling virological failure in HIV-infected children living in Africa

“…In retrospective study involving 1186 children in Ethiopia, Bacha et al found that chronic malnutrition was an independent predictor of first-line ART failure in children under 3 years of age [17]. In a study by Zanoni et al from South Africa, chronic diarrhea at baseline, independent of nutritional status and viral response, was predictive of poor CD4 recovery [70]. Given the relatively low cost and feasibility of nutritional supplementation, further exploration of its potential role in improving health outcomes in HIV-infected children is needed.…”