CD4 Decline and Incidence of Opportunistic Infections in Cape Town, South Africa

Boston University, Boston, Massachusetts, United States
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.56). 09/2006; 42(4):464-9. DOI: 10.1097/01.qai.0000225729.79610.b7
Source: PubMed


To determine the rate of CD4 decline and the incidence of opportunistic infections (OIs) among antiretroviral therapy-naive South African HIV-infected patients and inform timing of OI prophylaxis.
We used mixed-effect models to estimate CD4 cell decline by CD4 cell count strata in HIV-infected patients in the Cape Town AIDS Cohort between 1984 and 2000. Stratum-specific OI incidence per 100 person-years of observation was determined using incidence density analysis.
Nine hundred seventy-four patients with 2 or more CD4 cell counts were included. CD4 counts declined by 47.1 cells/microL per year in the stratum with more than 500 cells/microL stratum, 30.6 cells/microL per year in the stratum with 351 to 500 cells/microL, and 20.5 cells/microL per year in the stratum with 201 to 350 cells/microL. Tuberculosis and oral candidiasis were the only OIs that occurred frequently in the stratum with more than 200 CD4 cells/microL. Rates of chronic diarrhea, wasting syndrome, tuberculosis, and oral and esophageal candidiasis increased in the stratum with less than 200 cells/microL, and rates of all OIs were highest in the stratum with 50 cells/microL or less.
: CD4 cell count declines were dependent on CD4 strata and can inform timing of clinic visits and treatment initiation in South Africa. Incidence rates of OIs suggest that targeted OI prophylaxis could prevent substantial HIV-related morbidity in South Africa.

Download full-text


Available from: Robin Wood, Jul 10, 2014
  • Source
    • "Improvements in CD4 counts among those who started ART later were significantly better, a result expected from the effects of beginning ART earlier [18]. The improvements in CD4 counts were not more closely associated with improvements in opportunistic infection, surprising finding given results from other studies comparing CD4 counts with the incidence of such infections [19, 20]. Even allowing those opportunistic infections will still occur in those with higher CD4 counts; those infections should be milder and therefore require shorter average hospitalizations. "
    [Show abstract] [Hide abstract]
    ABSTRACT: . A 2010 evaluation found generally poor outcomes among HIV patients on antiretroviral therapy in Nicaragua. We evaluated an intervention to improve HIV nursing services in hospital outpatient departments to improve patient treatment and retention in care. The intervention included improving patient tracking, extending clinic hours, caring for children of HIV+ mothers, ensuring medication availability, promoting self-help groups and family involvement, and coordinating multidisciplinary care. Methods . This pre/postintervention study examined opportunistic infections and clinical status of HIV patients before and after implementation of changes to the system of nursing care. Hospital expenditure data were collected by auditors and hospital teams tracked intervention expenses. Decision tree analysis determined incremental cost-effectiveness from the implementers’ perspective. Results . Opportunistic infections decreased by 24% (95% CI: 14%–34%) and 11.3% of patients improved in CDC clinical stage. Average per-patient costs decreased by $133/patient/year (95% CI: $29–$249). The intervention, compared to business-as-usual strategy, saved money while improving outcomes. Conclusions . Improved efficiency of services can allow more ART-eligible patients to receive therapy. We recommended the intervention be implemented in all HIV service facilities in Nicaragua.
    Full-text · Article · May 2014
  • Source
    • "We used data from the Southern African Catholic Bishops Conference cohort to estimate mean age ± SD (37 ± 10 years), sex distribution (33% male), HIV RNA level distributions (46% with an HIV RNA level of > 100 000 copies/mL), and mean CD4+ T-cell count at ART initiation (112–178 cells/µL during 2004–2011) of the simulated cohorts [22, 23]. HIV disease natural history parameters, including chronic AIDS mortality and opportunistic disease incidence and mortality, were taken from the Cape Town AIDS Cohort [17]. Non-HIV mortality was estimated using United Nations life tables for South Africa, with adjustment to remove HIV-related mortality [18]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: We sought to quantify the survival benefits attributable to antiretroviral therapy (ART) in South Africa since 2004. Methods: We used the Cost-Effectiveness of Preventing AIDS Complications-International model (CEPAC) to simulate 8 cohorts of human immunodeficiency virus (HIV)-infected patients initiating ART each year during 2004-2011. Model inputs included cohort-specific mean CD4(+) T-cell count at ART initiation (112-178 cells/µL), 24-week ART suppressive efficacy (78%), second-line ART availability (2.4% of ART recipients), and cohort-specific 36-month retention rate (55%-71%). CEPAC simulated survival twice for each cohort, once with and once without ART. The sum of the products of per capita survival differences and the total numbers of persons initiating ART for each cohort yielded the total survival benefits. Results: Lifetime per capita survival benefits ranged from 9.3 to 10.2 life-years across the 8 cohorts. Total estimated population lifetime survival benefit for all persons starting ART during 2004-2011 was 21.7 million life-years, of which 2.8 million life-years (12.7%) had been realized by December 2012. By 2030, benefits reached 17.9 million life-years under current policies, 21.7 million life-years with universal second-line ART, 23.3 million life-years with increased linkage to care of eligible untreated patients, and 28.0 million life-years with both linkage to care and universal second-line ART. Conclusions: We found dramatic past and potential future survival benefits attributable to ART, justifying international support of ART rollout in South Africa.
    Full-text · Article · Dec 2013 · The Journal of Infectious Diseases
  • Source
    • "Tuberculosis is the most common opportunistic infection in HIV-infected individuals and is responsible for one-third of HIV-associated deaths [1]. HIV increases the risk of re-activation of latent tuberculosis infection (LTBI) from approximately 0.04 cases per 100 person years [2] to as high as more than 10 per 100 person years [3], [4], [5]. Isoniazid preventative treatment of HIV infected individuals with positive tuberculin skin tests (TST) has been shown to reduce the risk of developing active TB by 60% [6], and observational studies have shown an additive benefit when it is used alongside antiretroviral treatment [7], [8], [9]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Interferon gamma release assays (IGRAs) are used to diagnose latent tuberculosis infection. Two IGRAs are commercially available: the Quantiferon TB Gold In Tube (QFT-IT) and the T-SPOT.TB. There is debate as to which test to use in HIV+ individuals. Previous publications from high TB burden countries have raised concerns that the sensitivity of the QFT-IT assay, but not the T-SPOT.TB, may be impaired in HIV+ individuals with low CD4+ T-cell counts. We sought to compare the tests in a low TB burden setting. T-SPOT.TB, QFT-IT, and tuberculin skin tests (TST) were performed in HIV infected individuals. Results were related to patient characteristics. McNemar's test, multivariate regression and correlation analysis were carried out using SPSS (SPSS Inc). 256 HIV infected patients were enrolled in the study. The median CD4+ T-cell count was 338 cells/µL (range 1-1328). 37 (14%) patients had a CD4+ T-cell count of <100 cells/µL. 46/256 (18% ) of QFT-IT results and 28/256 (11%) of T-SPOT.TB results were positive. 6 (2%) of QFT-IT and 18 (7%) of T-SPOT.TB results were indeterminate. An additional 9 (4%) of T-SPOT.TB results were unavailable as tests were not performed due to insufficient cells or clotting of the sample. We found a statistically significant association between lower CD4+ T-cell count and negative QFT-IT results (OR 1.055, p = 0.03), and indeterminate/unavailable T-SPOT.TB results (OR 1.079, p = 0.02). In low TB prevalence settings, the QFT-IT yields more positive and fewer indeterminate results than T-SPOT.TB. Negative results on the QFT-IT and indeterminate/unavailable results on the T-SPOT.TB were more common in individuals with low CD4+ T-cell counts.
    Full-text · Article · Jan 2013 · PLoS ONE
Show more