Page 254 - HIVMED_v21_i1.indb

Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 4 Scientific Letter

CD4 testing after initiation of

antiretroviral therapy: Analysis of routine data

from the South African HIV programme

Authors: Background: People living with HIV (PLHIV) who have low CD4 counts require
Rivka R. Lilian 1 advanced clinical care (ACC) to minimise morbidity and mortality risk. These patients
Natasha Davies 1
Louise Gilbert 1 include immunological non-responders (INRs) with low CD4 counts despite a suppressed
1,2
James A. McIntyre viral load.
Helen E. Struthers
1,3
Kate Rees Objectives: To determine the proportion of patients with low CD4 counts after antiretroviral
1,4
therapy (ART) initiation and to describe INRs within that group.
Affiliations:
1 Anova Health Institute, Methods: Routine Three Interlinked Electronic Registers.Net (TIER.Net) data from four South
Johannesburg, South Africa African districts were analysed for adult PLHIV on ART > 12 months. Immunological non-
responders were defined as patients on ART > 4 years who were virally suppressed (viral load
2 School of Public Health and < 1000 copies/mL) with a CD4 count ≤ 350 cell/mm .
3
Family Medicine, University
of Cape Town, Cape Town, Results: Baseline CD4 was recorded for 80.9% of the 869 571 patients newly initiating ART,
South Africa
with 37.2% of those starting ART since 2017 having baseline counts ≤ 200 cells/mm . Amongst
3
3 Division of Infectious all 1 178 190 patients on ART, only 46.5% had a CD4 test after ART initiation and of these,
3
Diseases and HIV Medicine, 14.3% had CD4 ≤ 200 cells/mm . This proportion was highest amongst patients on ART ≤ 2
Department of Medicine, years (19.7%) (p < 0.001). Amongst virally suppressed patients, 20.0% were INRs. Immunological
University of Cape Town, non-response was significantly more likely amongst patients on second-line ART (adjusted
Cape Town, South Africa
odds ratio [aOR] 1.79), those aged 35-45 and ≥ 45 years (aOR 1.15 and 1.50, respectively), males
4 Department of Community (aOR 2.28) and patients with confirmed TB (aOR 2.49), and was significantly less likely in cases
Health, School of Public with higher baseline CD4 count (aOR 0.35).
Health, University of the
Witwatersrand, Johannesburg, Conclusion: CD4 testing subsequent to ART initiation is poorly implemented and there is a
South Africa notable proportion of patients with low CD4 counts. Guidelines regarding CD4 testing and
ACC need to be more widely implemented to identify patients with low CD4 counts and
Corresponding author: improve their outcomes.
Kate Rees,
[email protected]
Keywords: CD4; HIV; South Africa; advanced clinical care; immunological non-responder;
Dates: TIER.Net.
Received: 04 Sept. 2020
Accepted: 05 Oct. 2020
Published: 14 Dec. 2020 Introduction
How to cite this article: Antiretroviral therapy (ART) improves outcomes of people living with human immunodeficiency
Lilian RR, Davies N, Gilbert L, virus (PLHIV) by reducing HIV viral load (VL), which enables immune recovery, including recovery
et al. CD4 testing after
3
initiation of antiretroviral of CD4 count. Where patients have CD4 counts below 200 cells/mm , known as advanced HIV
therapy: Analysis of routine disease, advanced clinical care (ACC) should be provided to improve patient outcomes, including
data from the South African screening, management of opportunistic infections and focussed adherence support. Advanced
1
HIV programme. S Afr J HIV
Med. 2020;21(1), a1165. clinical care is particularly important in South Africa, considering that up to 40% of adults initiate
https://doi.org/10.4102/ ART with CD4 < 200 cells/mm . Furthermore, up to 50% of patients receiving ART demonstrate
3 2
sajhivmed.v21i1.1165 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. 7

South African guidelines include baseline CD4 testing for ART patients to assess cotrimoxazole
3
prophylaxis (CPT) eligibility (where CD4 count is ≤ 200 cells/mm ) and to determine susceptibility
Read online: 8
Read online:
Scan this QR
Scan this QR to opportunistic infections. CD4 monitoring should be repeated 12 months after ART initiation,
code with your 6 monthly until CPT eligibility ceases, 6 monthly if VL increases above 1000 copies/mL and if a
code with your
smart phone or
smart phone or 8
mobile device
mobile device patient requires re-initiation onto ART. Such CD4 testing is critical to ensure correct ACC
to read online.
to read online.
Copyright: © 2020. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.
http://www.sajhivmed.org.za 246 Open Access