Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
J Int AIDS Soc. 2020 Jul;23(7):e25546. doi: 10.1002/jia2.25546.
The World Health Organization (WHO) recommends a CD4 cell count before starting antiretroviral therapy (ART) to detect advanced HIV disease, and routine viral load (VL) testing following ART initiation to detect treatment failure. Donor support for CD4 testing has declined to prioritize access to VL monitoring. We examined trends in CD4 and VL testing among adults (≥15 years of age) starting ART in Southern Africa.
We analysed data from 14 HIV treatment programmes in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in 2005 to 2018. We examined the frequency of CD4 and VL testing, the percentage of adults with CD4 or VL tests, and among those having a test, the percentage starting ART with advanced HIV disease (CD4 count <200 cells/mm ) or failing to suppress viral replication (>1000 HIV-RNA copies/mL) after ART initiation. We used mixed effect logistic regression to assess time trends adjusted for age and sex.
Among 502,456 adults, the percentage with CD4 testing at ART initiation decreased from a high of 78.1% in 2008 to a low of 38.0% in 2017; the probability declined by 14% each year (odds ratio (OR) 0.86; 95% CI 0.86 to 0.86). Frequency of CD4 testing also declined. The percentage starting ART with advanced HIV disease declined from 83.3% in 2005 to 23.5% in 2018; each year the probability declined by 20% (OR 0.80; 95% CI 0.80 to 0.81). VL testing after starting ART varied; 61.0% of adults in South Africa and 10.7% in Malawi were tested, but fewer than 2% were tested in the other four countries. The probability of VL testing after ART start increased only modestly each year (OR 1.06; 95% CI 1.05 to 1.06). The percentage with unsuppressed VL was 8.6%. There was no evidence of a decrease in unsuppressed VL over time (OR 1.00; 95% CI 0.99 to 1.01).
CD4 cell counting declined over time, including testing at the start of ART, despite the fact that many patients still initiated ART with advanced HIV disease. Without CD4 testing and expanded VL testing many patients with advanced HIV disease and treatment failure may go undetected, threatening the effectiveness of ART in sub-Saharan Africa.
世界卫生组织（WHO）建议在开始抗逆转录病毒治疗（ART）之前进行 CD4 细胞计数，以检测晚期 HIV 疾病，并在开始 ART 后常规进行病毒载量（VL）检测，以检测治疗失败。由于捐赠支持 CD4 检测的减少，VL 监测的优先级得到了提高。我们研究了南部非洲开始接受 ART 的成年人（≥15 岁）中 CD4 和 VL 检测的趋势。
我们分析了来自莱索托、马拉维、莫桑比克、南非、赞比亚和津巴布韦 14 个 HIV 治疗项目 2005 年至 2018 年的数据。我们检查了 CD4 和 VL 检测的频率、有 CD4 或 VL 检测的成年人的百分比，以及在进行检测的成年人中，开始 ART 时患有晚期 HIV 疾病（CD4 计数<200 个细胞/mm）或 ART 启动后未能抑制病毒复制（>1000 HIV-RNA 拷贝/ml）的百分比。我们使用混合效应逻辑回归来评估调整年龄和性别后的时间趋势。
在 502456 名成年人中，在开始 ART 时进行 CD4 检测的百分比从 2008 年的 78.1%的峰值下降到 2017 年的 38.0%；每年下降 14%（优势比（OR）0.86；95%CI 0.86 至 0.86）。CD4 检测的频率也有所下降。开始 ART 时患有晚期 HIV 疾病的成年人的百分比从 2005 年的 83.3%下降到 2018 年的 23.5%；每年的概率下降 20%（OR 0.80；95%CI 0.80 至 0.81）。ART 启动后的 VL 检测情况有所不同；南非 61.0%的成年人和马拉维 10.7%的成年人接受了检测，但其他四个国家的检测比例均低于 2%。ART 启动后进行 VL 检测的概率每年仅略有增加（OR 1.06；95%CI 1.05 至 1.06）。未抑制的 VL 比例为 8.6%。没有证据表明未抑制的 VL 随时间减少（OR 1.00；95%CI 0.99 至 1.01）。
尽管许多患者仍以晚期 HIV 疾病开始接受 ART，但 CD4 细胞计数随时间下降，包括在 ART 开始时的检测。如果没有 CD4 检测和扩大的 VL 检测，许多患有晚期 HIV 疾病和治疗失败的患者可能会未被发现，从而威胁到撒哈拉以南非洲地区的 ART 有效性。
