Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA.
J Acquir Immune Defic Syndr. 2013 May 1;63(1):34-41. doi: 10.1097/QAI.0b013e318287c1fe.
In many resource-limited settings monitoring of combination antiretroviral therapy (cART) is based on the current CD4 count, with limited access to HIV RNA tests or laboratory diagnostics. We examined whether the CD4 count slope over 6 months could provide additional prognostic information.
We analyzed data from a large multicohort study in South Africa, where HIV RNA is routinely monitored. Adult HIV-positive patients initiating cART between 2003 and 2010 were included. Mortality was analyzed in Cox models; CD4 count slope by HIV RNA level was assessed using linear mixed models.
About 44,829 patients (median age: 35 years, 58% female, median CD4 count at cART initiation: 116 cells/mm) were followed up for a median of 1.9 years, with 3706 deaths. Mean CD4 count slopes per week ranged from 1.4 [95% confidence interval (CI): 1.2 to 1.6] cells per cubic millimeter when HIV RNA was <400 copies per milliliter to -0.32 (95% CI: -0.47 to -0.18) cells per cubic millimeter with >100,000 copies per milliliter. The association of CD4 slope with mortality depended on current CD4 count: the adjusted hazard ratio (aHRs) comparing a >25% increase over 6 months with a >25% decrease was 0.68 (95% CI: 0.58 to 0.79) at <100 cells per cubic millimeter but 1.11 (95% CI: 0.78 to 1.58) at 201-350 cells per cubic millimeter. In contrast, the aHR for current CD4 count, comparing >350 with <100 cells per cubic millimeter, was 0.10 (95% CI: 0.05 to 0.20).
Absolute CD4 count remains a strong risk for mortality with a stable effect size over the first 4 years of cART. However, CD4 count slope and HIV RNA provide independently added to the model.
在许多资源有限的环境中，组合抗逆转录病毒疗法（cART）的监测基于当前的 CD4 计数，对 HIV RNA 检测或实验室诊断的获取有限。我们研究了 CD4 计数斜率在 6 个月内是否能提供额外的预后信息。
我们分析了南非一项大型多队列研究的数据，该研究中常规监测 HIV RNA。将 2003 年至 2010 年间开始接受 cART 的成年 HIV 阳性患者纳入分析。采用 Cox 模型分析死亡率；采用线性混合模型评估 HIV RNA 水平下的 CD4 计数斜率。
约 44829 例（中位年龄 35 岁，58%为女性，cART 起始时的中位 CD4 计数为 116 个细胞/mm）患者中位随访 1.9 年，有 3706 例死亡。当 HIV RNA<400 拷贝/ml 时，每周平均 CD4 计数斜率为 1.4[95%置信区间（CI）：1.2 至 1.6]个细胞/mm；而当 HIV RNA>100000 拷贝/ml 时，平均斜率为-0.32（95%CI：-0.47 至-0.18）个细胞/mm。CD4 斜率与死亡率的相关性取决于当前的 CD4 计数：与 6 个月内 CD4 增加>25%相比，6 个月内 CD4 减少>25%的调整后危险比（aHR）为 0.68（95%CI：0.58 至 0.79），而在当前 CD4 计数为 201-350 个细胞/mm 时为 1.11（95%CI：0.78 至 1.58）。相比之下，当前 CD4 计数>350 与<100 个细胞/mm 时的 aHR 为 0.10（95%CI：0.05 至 0.20）。
绝对 CD4 计数仍然是死亡率的一个强有力的危险因素，在 cART 的前 4 年中具有稳定的效应大小。然而，CD4 计数斜率和 HIV RNA 独立地为模型提供了补充。
