Prevalence, predictors and HIV disease progression in immunovirogical discordant HIV patients at 12 months of first line antiretroviral therapy in Zambia.
Date
2019
Authors
Sivile, Suilanji
Journal Title
Journal ISSN
Volume Title
Publisher
The University of Zambia
Abstract
Combined antiretroviral therapy (cART) has improved mortality and morbidity among HIV-infected patients. However, a third of HIV-infected patients still present to care with advanced disease despite the rollout of cART. Some of these patients fail to appropriately reconstitute their immune system despite being on effective cART signified by a suppressed viral load. This phenomenon is termed immunovirological discordance. These patients remain immunocompromised and could still be at risk of opportunistic infections and subsequent mortality. As the HIV population is getting older, immune senescence and its impact on discordance has become topical. Understanding the prevalence and predictors of this
phenomenon is crucial for the HIV response. A cross-sectional study was conducted in 20 health facilities throughout Zambia selected based on probability proportion to size method. Adult HIV patients with a suppressed viral load at 12 months of first line cART were enrolled. Relevant blood samples were drawn and a questionnaire was completed with the aid of the hospital chart . Adequate immune response was defined as an increase of baselines CD4cell count to >200cells/μL at 12 months of ART and/or an absolute CD4cell count change of >150cells/μL. We used multivariate logistic models to identify predictors for immunovirological discordance. 360 patients were enrolled. 57% were females. 68% were 25-44 years old. 17% had a CD4cell count below 200cells/μL at 12 months of ART and 54% had an absolute CD4cell count change of less than 150cells/μL. Females were 2 times more likely to have a CD4cell count above 200cells/μL (OR 2: 95%CI 1.00-3.62;P=0.028) and patients with a body mass index >25kg/m2 were 4 times more likely to have a high CD4 count compared to those underweight (OR 4:95% CI 1.29-13.73; P=0.017) . A baseline CD4cell count below 200cells/μL was a predictor for an absolute CD4cell count change of less than 150cells/μL (OR12:95% CI 4.04-33.41; P= <0.0001). Hepatitis B virus positive status (OR 0.03:95% CI 0.003-0.25; P= 0.001) and baseline WHO stageIV/III disease (OR 0.01:95% CI 0.01-0.59; P=0.0001) were predictors for suboptimal CD4cell response. Patient’s age, Positive RPR, TNF levels and CRP levels were not associated with suboptimal CD4cell recovery. There was no association between WHO Clinical Stage at 12 months of cART with immunovirological discordance.
In patients with viral load suppression at 12 months of cART, immunovirological discordance is common. Baseline CD4cell count, male sex, baseline low BMI, HBV infection and baseline WHO clinical stage III/IV could predict immunovirological discordance. Markers of morbidity such as high CRP levels and advanced WHO clinical staging at 12 months of cART are not necessarily associated with suboptimal immune response. Early commencement of cART may prevent immunovirological discordance, a finding which supports the ‘test and start’ strategy. Further investigation in understanding the immunology of discordance and its clinical outcomes are proposed.
Description
Thesis in Masters of Medicine (Internal Medicine and Infectious diseases)