Late treatment in Africa may disadvantage those with HIV for years.Starting antiretroviral antiretroviral /an·ti·ret·ro·vi·ral/ (-ret´ro-vi?ral) effective against retroviruses, or an agent with this quality.
adj. therapy earlier, before the development of symptoms, is the most likely way to reduce the high death rates after treatment initiation seen in people with HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. in resource-limited settings, two large cohort cohort /co·hort/ (ko´hort)
1. in epidemiology, a group of individuals sharing a common characteristic and observed over time in the group.
2. analyses show. The studies also show that the major disadvantage of starting treatment late--an increased risk of death--may persist for some years, burdening already overstretched o·ver·stretch
v. o·ver·stretched, o·ver·stretch·ing, o·ver·stretch·es
1. To stretch excessively; overstrain.
2. To stretch or extend over.
v.intr. health systems with illness that could be avoided by earlier treatment.
The findings, presented last week at the Sixteenth Conference on Retroviruses and Opportunistic Infections Opportunistic infections
Infections that cause a disease only when the host's immune system is impaired. The classic opportunistic infection never leads to disease in the normal host. in Montreal, are likely to strengthen the case for a stronger global recommendation that people with HIV should start treatment when the CD4 cell CD4 cell CD4+ lymphocyte A circulating T cell with a 'helper' phenotype; in AIDS Pts, the levels of CD4+ cells is a crude indicator of immune status and susceptibility to certain AIDS-related conditions; these Pts may suffer KS as CD4+ cells fall below 0. count falls below 350 cells/[mm.sup.3], wherever resources permit.
Current World Health Organization guidelines guidelines,
n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. endorse To sign a paper or document, thereby making it possible for the rights represented therein to pass to another individual. Also spelled indorse.
endorse (indorse) v. treatment for anyone with a CD4 count CD4 count
A measure of the number of helper T cells per cubic millimeter of blood, used to analyze the prognosis of patients infected with HIV. below 200, and advise clinicians to 'consider' treatment in anyone with a CD4 count between 200 and 350 cells/[mm.sup.3], with the aim that treatment should start before the CD4 count falls below 200 cells/[mm.sup.3].
Current national guidelines in many countries in Asia and sub-Saharan Africa continue to emphasise treatment for those with CD4 counts below 200 cells/[mm.sup.3], due to concerns about the cost of treatment and the capacity to deliver it to larger numbers of patients.
However, there is accumulating evidence that, due to late diagnosis, many people are continuing to start HIV treatment very late--often at CD4 counts below 50 cells/[mm.sup.3]. These individuals are much more likely to die or develop serious illnesses after starting treatment and, as Dr Stephen Lawn of the University of Cape Town
“UCT” redirects here. For other uses, see UCT (disambiguation). pointed out to the conference, 'Our hospitals are chock-a-block and just can't cope' as a consequence of the failure to identify patients with HIV earlier and to begin treatment earlier. A systematic review of published studies by Stephen Lawn and colleagues shows death rates of between 8% and 26% among cohorts starting treatment late.
The two studies presented at CROI CROI Conference on Retroviruses and Opportunistic Infections 2009 provide compelling evidence of the costs of late treatment initiation, for people with HIV in terms of lives lost, and for health systems in terms of the burden of avoidable disease occurring as a result of late identification and treatment of people with HIV infection.
The consequences of late treatment initiation in Gugulethu, South Africa South Africa, Afrikaans Suid-Afrika, officially Republic of South Africa, republic (2005 est. pop. 44,344,000), 471,442 sq mi (1,221,037 sq km), S Africa.
Stephen Lawn presented results from patients receiving antiretroviral treatment through a community-based programme in Gugulethu, a township township: see town. near Cape Town Cape Town or Capetown, city (1991 pop. 854,616), legislative capital of South Africa and capital of Western Cape, a port on the Atlantic Ocean. It was the capital of Cape Province before that province's subdivision in 1994. . The study looked at the risk of death not only on the basis of the CD4 count at the time treatment was started, but on the basis of the updated CD4 count at specific time-points during the 4-year follow-up period.
Follow-up data were available for 2 423 people who had initiated antiretroviral therapy, observed for 3 155 person-years. The study population's median baseline cell count was 105 cells/[mm.sup.3]; CD4 cell count levels were subsequently measured at 4-month intervals.
The cumulative mortality after 48 months of follow-up was 13.2%, lower than many cohorts in Africa, but among individuals who started treatment with a CD4 count below 100 and an AIDS-related illness, the 48-month cumulative mortality was 24.8%.
There were 197 deaths, with the following associations between updated CD4 cell count levels and mortality rate ratios: 0-49 cells/[mm.sup.3] 11.6; 50 - 99 cells/[mm.sup.3] 4.9; 100 - 199 cells/[mm.sup.3] 2.6; 200 - 299 cells/[mm.sup.3] 1.7; 300 - 399 cells/[mm.sup.3] 1.5; 400 - 499 cells/[mm.sup.3] 1.4; and 500 cells/[mm.sup.3] or more 1.0.
When the researchers calculated persontime within updated CD4 cell count strata, they found high mortality during the first year of treatment to be related to the large proportion of person-time spent at less than 200 CD4 cells/[mm.sup.3]. People with less than 100 CD4 cells/[mm.sup.3] had higher cumulative mortality estimates at 1 and 4 years than those whose baseline CD4 cell counts were higher (1-year: 11.6% v. 5.2% mortality; 4-year: 16.7% v. 9.5% mortality).
The researchers attribute this to persontime spent at low CD4 cell counts, and conclude: 'National HIV programmes in resource-limited settings should be designed to minimise the time that patients spend with CD4 counts [below] 200 cells/[mm.sup.3] both before and during [use of antiretroviral therapy].' Dr Lawn said that health systems have two options: either continue in 'firefighting' mode, treating AIDS-related illnesses as they arise in people who start treatment late, or treat people earlier and reduce the burden of mortality and morbidity morbidity /mor·bid·i·ty/ (mor-bid´it-e)
1. a diseased condition or state.
2. the incidence or prevalence of a disease or of all diseases in a population.
n. caused by HIV. But he warned: 'Firefighting is very difficult and time-consuming and takes up a huge amount of resources'. Mortality in people with HIV compared with background population levels
The other study compared the mortality rates of antiretroviral-treated people in four sub-Saharan African countries with all-cause mortality in the corresponding populations. HIV-related mortality data were drawn from antiretroviral treatment programmes in Ivory Coast Ivory Coast: see Côte d'Ivoire. , Malawi, South Africa and Zimbabwe. The researchers used estimates from the World Health Organization (WHO) Global Burden of Disease project to calculate the expected numbers of non-HIV-related deaths in the relevant populations.
Data on clinical stage of HIV disease were available for 13 249 HIV-positive people It may never be fully completed or, depending on its its nature, it may be that it can never be completed. However, new and revised entries in the list are always welcome. with 14 695 person-years of follow-up; 85% had advanced disease when they began taking antiretroviral therapy. A total of 1 177 deaths occurred during 14 695 person-years of follow-up, a cumulative mortality of 11.7%.
They found that people with advanced HIV disease (<50 cells/[mm.sup.3]) had a mortality rate 500 times higher than the background rate in the local population, and among those who started treatment with a CD4 count below 25 cells/[mm.sup.3] the mortality rate remained 47 times higher than the background rate in the local population after 2 years of follow-up. Among those who started treatment without symptoms and a CD4 count above 200 the mortality rate remained slightly elevated compared with the general population, but was substantially lower than that seen in those who started treatment much later (1.24 to 3.4-fold higher than the general population).
Presenting the results, Martin Brinkhof of the University of Berne, concluded that while there is greater mortality among HIV-positive people taking antiretroviral therapy than in the general population, 'for some patients the excess is moderate and mortality reaches that of the general population in the second year of [antiretroviral therapy]'. They add that more timely initiation of antiretroviral therapy might prevent much of the excess mortality.
Brinkhof M, et al. Mortality of HIV-infected patients starting ART: comparisons with the general population in Southern Africa
Lawn S, et al. Changing mortality risk associated with CD4 cell response to long-term ART: Sub-Saharan Africa. Sixteenth Conference on Retroviruses and Opportunistic Infections, Montreal, abstract 140, 2009.
This article is courtesy of NAM/aidsmap.com