Page 239 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 7 Original Research

first month of ART by 75 cells/µL–100 cells/µL, with a more status, year of initiation, baseline body mass index (BMI),
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gradual response thereafter. The CD4+ cell count of some HIV clinical stage, haemoglobin and estimated glomerular
patients, however, fails to increase despite viral suppression. filtration rate (eGFR), along with the serial CD4+ cell counts
Several causes have been suggested for this ‘immuno- and VL measurements. The study population included
virologic discordant’ CD4+ cell response. Insufficient individuals initiated on cART between 01 January 2004 and
thymic activity and ongoing viral replication, despite good 31 July 2016 and stored on tier.net. This included those
viral suppression, may account for this. Some studies transferred into the facility and those initiated at the facility.
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have investigated the implication of immuno-virologic The database (tier.net) also had some missing data. Many
discordance. Zoufaly et al. found that compared with those patients did not have any VL and/or CD4 cell count results
whose CD4+ cell count increases with viral suppression, recorded even after 6 months, and as a result they were
patients with immuno-virologic discordance had increased excluded from the study. Also excluded were those who
risk for developing AIDS and other complications, especially defaulted and reinitiated later. Therefore, their duration on
in the first 6 months of therapy. Several factors have been cART could not be correctly determined.
shown to be associated with viral suppression, adequate
CD4+ cell response and immuno-virologic discordance. 12 Typical first-line antiretroviral regimen consisted of stavudine,
lamivudine and nevirapine or efavirenz, prior to 2010.
It is known that poor adherence to antiretrovirals is associated Stavudine was replaced with tenofovir after 2010, with a
with failure to suppress HIV. The best indicator of adherence fixed-dose combination (FDC) introduced in 2012. Second-
and response to treatment is virologic response, and more line highly active antiretroviral therapy (HAART) consisted
than 90% – 95% adherence is required to achieve viral of abacavir or zidovudine, combined with lamivudine and
suppression. Other factors have also been shown to be ritonavir-boosted lopinavir. Third-line regimen was to be
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associated with a delay in or failure to attain viral suppression. decided by a review committee. 8,17,18
Devey et al. stated that the age group less than 15 years,
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male gender, prior ART exposure and being on tuberculosis
treatment were associated with an increased risk of virologic Outcomes
failure in South Africa. However, in Swaziland, Jobanputra Immunologic and virologic response
et al. found that age group less than 20 years and CD4 Virologic and immunologic responses were measured up to
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count less than 350 cells/µL were associated with virologic 132 months after cART initiation. Virologic response was
failure. In contrast, gender was not an associated factor. measured using plasma HIV RNA concentrations. A VL of
Another factor associated with higher incidence of viral less than 50 copies/mL was considered suppressed. Because
failure is a high VL at initiation. A high CD4+ cell count and of differences in types of VL assays used over the period
better clinical stage at initiation are, however, associated under review, analysis was also done using a VL less than
with earlier viral suppression. Finally, Bello et al. found 400 copies/mL as viral suppression. Immunologic response
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16
that a longer duration post-cART initiation, less previous was measured by CD4+ cell count. An increase in CD4+ cell
antiretroviral drug use before lifelong cART, higher baseline count of at least 50 cells/µL at 6 months after cART initiation
CD4 cell count and lower baseline VL were associated with was considered as adequate. If an individual had more
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10 years of sustained viral suppression. than one VL or CD4+ cell count measurement at a fixed
Objectives interval, the result closest to the particular interval was used.
The sustainability of viral suppression was also reviewed.
The main objective of this study was to investigate the This was defined as having at least two consecutive VL
virologic and immunologic responses of patients, in a rural results that were at most 50 copies/mL. The association of
community health centre in South Africa, to cART, as well other covariates with these responses was also evaluated.
as the factors that are associated with these responses.
Individuals who had been on cART for less than 6 months Mortality
were excluded from the study, as the minimum time required Mortality was determined exclusively as recorded on tier.net.
to determine response was 6 months. 8 However, the recording of death on tier.net was not
corroborated with national mortality database. This may
Methodology have affected the validity of a more detailed analysis.

Study population and design
Statistical analysis
A retrospective review was performed on the database
(electronic and paper records) of Thohoyandou Community The data used for the study were extracted from tier.net.
Health Centre (TCHC), which has one of the highest number Data not found on tier.net were retrieved from paper folders
of patients on cART in Vhembe District. TCHC is located in of individual patients. It was converted, using Microsoft
Thulamela Municipality in Vhembe District, which is the Excel 2010, into a format for analysis in SPSS software version
northernmost district in Limpopo Province, South Africa. 24.0. Descriptive and inferential statistics were generated.
It is a public health facility. A data collection form was During data cleaning, duplicate entries were identified and
designed to retrieve the data, including age, sex, marital removed. The data set for socio-demographic variables and

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