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Abstract
Very low CD4 T cell counts and low total lymphocyte counts at initiation of HAART are associated with a poor outcome in the first 6 months of antiretroviral treatment
H. Mayanja-Kizza1, F. Lutwama2, M. Kamya3, C. Kikawa2, L. Spacek4, T. Quinn4
1Makerere University, Faculty of Medicine, Academic Alliance for AIDS Care and Prevention, Kampala, Uganda, 2Makerere University Infectious Diseases Institute, Kampala, Uganda, 3Makerere University Infectious Diseases Institute/ Academic Alliance for AIDS Care and Prevention, Kampala, Uganda, 4Johns Hopkins University, Public Health, Baltimore, United States
Background: Global HAART scale up efforts have increased access to AIDS treatment in developing countries, but mortality remains high despite adequate management.
Methods: A cohort of 550 patients starting HAART were prospectively followed up over thirty months at an AIDS treatment center in Kampala, Uganda. Regular clinical review; and CD4 T cell and viral load counts were done every 3 and 6 months respectively. Early home visits to locate those who missed clinical appointments were done. Data was compared to patients alive after over twelve months of HAART.
Results: Seventy two (13%), patients (45 females, mean age 36.7 (SD 19) and 27 men, 39.3 (SD 6) years), died while on ARVs despite over 90% adherence. Twenty nine died within 6 months of commencement of ARVs, 24 between 6-12 months and 19 died after one year. HAART was started at very low CD4s, median 24 cells/mm3 among those who died, (deaths within 6, 6-12, over 12 months of HAART, median CD4T cells 14 cells/mm3, 31 cells/mm3, 73 cells/mm3 respectively) compared to 110 cells/mm3 among over 12 months survivors (p=0.002). Initial total lymphocyte counts were significantly lower among deaths within 6 months, mean 1200/mm3, (SD 720) compared to deaths over one year 1800 cells/mm3, (SD 1038) and survivors 1780 (SD 1120) (p=0.028). Viral load at onset of HAART was similar in all groups, mean 5.5 log among survivors, and 5.7 log among all deaths. There was better viral load suppression at 12 months 2.9 log among survivors, compared to 0.4 log among deaths over one year (p=0.005).
Conclusions: High mortality on HAART may be associated with late commencement of treatment at very low CD4 counts, where despite adequate treatment immune recovery lags behind virological suppression. Commencing HAART at earlier CD4 counts should be considered, even in resource limited countries to improve outcome.
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