Bray Sarah, Gedeon Jillian, Hadi Ahsan, Kotb Ahmed, Rahman Tarun, Sarwar Elaha, Savelyeva Anna, Sévigny Marika, Bakanda Celestin, Birungi Josephine, Chan Keith, Yaya Sanni, Deonandan Raywat, Mills Edward J
Interdisciplinary School of Health Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
HIV AIDS (Auckl). 2012;4:135-40. doi: 10.2147/HIV.S35374. Epub 2012 Aug 17.
Although international guidelines recommend initiating antiretroviral therapy (ART) when a patient's CD4 cell count is ≤350 cells/μL, most patients in resource-limited settings present with much lower CD4 cell counts. The lowest level that their CD4 cell count reaches, the nadir, may have long-term consequences in terms of mortality. We examined this health state in a large cohort of HIV+ patients in Uganda.
This was an observational study of HIV patients in Uganda aged 14 years or older, who were enrolled in 10 major clinics across Uganda.
We assessed the CD4 nadir of patients, using their CD4 cell count at initiation of ART, stratified into categories (,50, 50-99, 100-149, 150-249, 250+ cells/μL). We constructed Kaplan-Meier curves to assess the differences in survivorship for patients left-censored at 1 year and 2 years after treatment initiation. We used Cox proportional hazards regression to model the associations between CD4 nadir and mortality. We adjusted mortality for loss-to-follow-up.
Of 22,315 patients, 20,129 patients had greater than 1 year of treatment follow-up. Among these patients, 327 (1.6%) died and 444 (2.2%) were lost to follow-up. After left-censoring at one year, relative to lowest CD4 strata, patients with higher CD4 counts had significantly lower rates of mortality (CD4 150-249, hazard ratio [HR] 0.60, 95% confidence interval [CI]: 0.45-0.82, P = 0.001; 250+, HR 0.66, 95% CI, 0.44-1.00, P = -0.05). Male sex, older age, and duration of time on ART were independently associated with mortality. When left-censoring at 2 years, CD4 nadir was no longer statistically significantly associated with mortality.
After surviving for 1 year on ART, a CD4 nadir was strongly predictive of longer-term mortality among patients in Uganda. This should argue for efforts to increase engagement with patients to ensure a higher CD4 nadir at initiation of treatment.
尽管国际指南建议当患者的CD4细胞计数≤350个/微升时开始抗逆转录病毒治疗（ART），但资源有限地区的大多数患者就诊时CD4细胞计数要低得多。他们CD4细胞计数达到的最低水平，即最低点，可能在死亡率方面产生长期后果。我们在乌干达的一大群HIV阳性患者中研究了这种健康状况。
这是一项对乌干达14岁及以上HIV患者的观察性研究，这些患者在乌干达的10家主要诊所登记入组。
我们使用患者开始接受ART时的CD4细胞计数评估其CD4最低点，并将其分层（＜50、50 - 99、100 - 149、150 - 249、250+个/微升）。我们构建了Kaplan - Meier曲线，以评估治疗开始后1年和2年进行左删失的患者在生存率方面的差异。我们使用Cox比例风险回归模型来模拟CD4最低点与死亡率之间的关联。我们对失访情况进行了死亡率调整。
在22315名患者中，20129名患者有超过1年的治疗随访。在这些患者中，327名（1.6%）死亡，444名（2.2%）失访。在1年进行左删失后，相对于最低CD4分层，CD4计数较高的患者死亡率显著较低（CD4 150 - 249，风险比[HR] 0.60，95%置信区间[CI]：0.45 - 0.82，P = 0.001；250+，HR 0.66，95% CI，0.44 - 1.00，P = 0.05）。男性、年龄较大以及接受ART的时间长短与死亡率独立相关。在2年进行左删失时，CD4最低点与死亡率不再具有统计学显著关联。
在接受ART治疗1年后存活的患者中，CD4最低点强烈预测乌干达患者的长期死亡率。这表明应努力加强与患者的接触，以确保治疗开始时具有更高的CD4最低点。
