Article

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

ABSTRACT

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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    • "A review focussing on micronutrient supplements in HIV found some evidence of benefits of multiple micronutrient supplements for CD4 count [18]; however, evidence was limited and much of the research focussed on pregnant women or was conducted before ART was widely available. Thus, vitamin and mineral supplementation to improve immunological recovery in seriously ill HIV patients clearly merits further investigation , especially since early robust recovery of CD4 count may be particularly important for survival of patients with a low BMI [35] . Other aspects of nutritional recovery are among the NUSTART trial secondary outcomes to be reported later. "
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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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