Early immunologic response and subsequent survival among malnourished adults receiving antiretroviral therapy in Urban Zambia

Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
AIDS (London, England) (Impact Factor: 5.55). 08/2010; 24(13):2117-21. DOI: 10.1097/QAD.0b013e32833b784a
Source: PubMed


To evaluate the relationship between early CD4(+) lymphocyte recovery on antiretroviral therapy (ART) and subsequent survival among low body mass index (BMI) HIV-1-infected adults.
Retrospective analysis of a large programmatic cohort in Lusaka, Zambia.
We evaluated ART-treated adults enrolled in care for more than 6 months. We stratified this study population according to World Health Organization (WHO) malnutrition criteria: normal (BMI >or=18.5 kg/m(2)), mild (17.00-18.49), moderate (16.00-16.99), and severe (<16.0). We used Cox proportional hazards regression to estimate the subsequent risk of death associated with absolute CD4(+) cell count change over the first 6 months on ART. To account for effect modification associated with baseline CD4(+) cell count, a weighted summary measure was calculated.
From May 2004 to February 2009, 56,612 patients initiated ART at Lusaka district clinics; of these, 33 097 (58%) were included in this analysis. The median change in 0-6 month CD4(+) cell count in each baseline BMI strata varied from 127 to 131 cells/microl. There was a statistically significant, inverse association between baseline BMI and the post 6-month hazard for mortality only among those patients with less than 100 cells/microl increase in the first 6 months of ART. A CD4(+) cell count increase of at least 100 cells/microl over the first 6 months of ART was not associated with a higher hazard for mortality, regardless of baseline BMI.
Low baseline BMI and attenuated CD4(+) cell count response at 6 months had a compounding, negative impact on post 6-month survival. Specific guidelines for monitoring ART response using immunologic criteria may be warranted for low BMI patients.

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    • "Although our patients presented with very low baseline CD4 counts at both levels of care, the two groups achieved impressive immunologic response to ART in the first year with patients at the prime site achieving significantly higher increases. Studies reporting immunologic response to ART in Africa [23–25] have obtained similar margins of CD4 increase among patients on ART, with slightly lower increases among older age groups. The use of prophylactic agents such as cotrimoxazole among other initiatives will help to further improve immune function and sustain the benefits of ART as programs scale out to rural areas with high burden of OIs. "
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    ABSTRACT: Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug nave patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (íµí±ƒ < 0.001) and 24 weeks (íµí±ƒ < 0.001) with similar responses at 48 weeks (íµí±ƒ = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (íµí±ƒ < 0.001) and 48 weeks (íµí±ƒ = 0.03), but similar responses at 24 weeks (íµí±ƒ = 0.21). Mortality was 2.3% versus 5.0% (íµí±ƒ < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (íµí±ƒ = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care.
    AIDS research and treatment 06/2014; 2014. DOI:10.1155/2014/560623
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    • "Despite the tremendous benefits of antiretroviral therapy (ART) use on HIV disease progression and survival [1], [2], micro- and macronutrient malnutrition remain strong independent predictors of mortality among HIV-positive individuals in both high and low resource settings [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. A growing body of evidence suggests that socio-economic determinants may also adversely impact survival among people living with HIV/AIDS [14], [15]. "
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    ABSTRACT: Little is known about the potential impact of food insecurity on mortality among people living with HIV/AIDS. We examined the potential relationship between food insecurity and all-cause mortality among HIV-positive injection drug users (IDU) initiating antiretroviral therapy (ART) across British Columbia (BC). Cross-sectional measurement of food security status was taken at participant ART initiation. Participants were prospectively followed from June 1998 to September 2011 within the fully subsidized ART program. Cox proportional hazard models were used to ascertain the association between food insecurity and mortality, controlling for potential confounders. Among 254 IDU, 181 (71.3%) were food insecure and 108 (42.5%) were hungry. After 13.3 years of median follow-up, 105 (41.3%) participants died. In multivariate analyses, food insecurity remained significantly associated with mortality (adjusted hazard ratio [AHR] = 1.95, 95% CI: 1.07-3.53), after adjusting for potential confounders. HIV-positive IDU reporting food insecurity were almost twice as likely to die, compared to food secure IDU. Further research is required to understand how and why food insecurity is associated with excess mortality in this population. Public health organizations should evaluate the possible role of food supplementation and socio-structural supports for IDU within harm reduction and HIV treatment programs.
    PLoS ONE 05/2013; 8(5):e61277. DOI:10.1371/journal.pone.0061277 · 3.23 Impact Factor
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    • "Early mortality in the initial 90 days after antiretroviral therapy (ART) initiation is strikingly high among persons with low body mass index (BMI < 18.5 kg/m 2 ) compared to those with normal BMI [1] [2] [3] [4]. While a greater incidence of opportunistic infections and more advanced immunosuppression likely contributes to increased mortality in undernourished patients [5] [6], the loss of metabolically active tissue may negatively impact a range of critical physiologic processes and also contribute to these early deaths [7] [8] [9]. Skeletal muscle mass, a major reservoir of bioavailable phosphate, is reduced early in HIV-associated weight loss, and among HIV-uninfected persons chronic undernutrition is associated with a reduction in mitochondrial enzyme activity which rapidly normalizes with nutritional support [10] [11] [12]. "
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    Journal of nutrition and metabolism 04/2013; 2013(4):545439. DOI:10.1155/2013/545439
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