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CD4 count at antiretroviral therapy initiation and the risk of loss to follow-up: results from a multicentre cohort study
  1. Anna Grimsrud1,
  2. Morna Cornell1,2,
  3. Michael Schomaker2,
  4. Matthew P Fox3,4,5,
  5. Catherine Orrell6,
  6. Hans Prozesky7,8,
  7. Kathryn Stinson2,9,
  8. Frank Tanser10,
  9. Matthias Egger11,
  10. Landon Myer1,2
  11. for the International Epidemiologic Databases to Evaluate AIDS Southern Africa Collaboration (IeDEA-SA)
  1. 1Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
  2. 2Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
  3. 3Center for Global Health & Development, Boston University, Boston, Massachusetts, USA
  4. 4Department of Internal Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
  5. 5Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
  6. 6Faculty of Health Sciences, Desmond Tutu HIV Centre, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
  7. 7Division of Infectious Diseases, Department of Medicine, University of Stellenbosch, Cape Town, South Africa
  8. 8Tygerberg Academic Hospital, Cape Town, South Africa
  9. 9Médecins Sans Frontières, Cape Town, South Africa
  10. 10Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
  11. 11Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
  1. Correspondence to Dr Anna Grimsrud, Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa; agrimsrud{at}gmail.com

Abstract

Background Antiretroviral therapy (ART) initiation is now recommended irrespective of CD4 count. However data on the relationship between CD4 count at ART initiation and loss to follow-up (LTFU) are limited and conflicting.

Methods We conducted a cohort analysis including all adults initiating ART (2008–2012) at three public sector sites in South Africa. LTFU was defined as no visit in the 6 months before database closure. The Kaplan-Meier estimator and Cox's proportional hazards models examined the relationship between CD4 count at ART initiation and 24-month LTFU. Final models were adjusted for demographics, year of ART initiation, programme expansion and corrected for unascertained mortality.

Results Among 17 038 patients, the median CD4 at initiation increased from 119 (IQR 54–180) in 2008 to 257 (IQR 175–318) in 2012. In unadjusted models, observed LTFU was associated with both CD4 counts <100 cells/μL and CD4 counts ≥300 cells/μL. After adjustment, patients with CD4 counts ≥300 cells/μL were 1.35 (95% CI 1.12 to 1.63) times as likely to be LTFU after 24 months compared to those with a CD4 150–199 cells/μL. This increased risk for patients with CD4 counts ≥300 cells/μL was largest in the first 3 months on treatment. Correction for unascertained deaths attenuated the association between CD4 counts <100 cells/μL and LTFU while the association between CD4 counts ≥300 cells/μL and LTFU persisted.

Conclusions Patients initiating ART at higher CD4 counts may be at increased risk for LTFU. With programmes initiating patients at higher CD4 counts, models of ART delivery need to be reoriented to support long-term retention.

  • EPIDEMIOLOGY
  • HIV
  • INTERNATIONAL HLTH
  • LONGITUDINAL STUDIES

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