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Unformatted text preview: C LINICAL S CIENCE CD4 + T-Cell Count Monitoring Does Not Accurately Identify HIV-Infected Adults With Virologic Failure Receiving Antiretroviral Therapy David M. Moore, MDCM, MHSc,*†‡ Anna Awor, MSc,* Robert Downing, PhD,* Jonathan Kaplan, MD, MPH,§ Julio S. G. Montaner, MD,†‡ John Hancock, MSc,* Willy Were, MBChB, MPH,* and Jonathan Mermin, MD, MPH* Background: CD4 + T-lymphocyte (CD4) counts are widely used to monitor response to antiretroviral therapy (ART) in resource-limited settings. However, the utility of such monitoring in terms of predicting virologic response to therapy has been little studied. Methods: We studied participants aged 18 years and older who initiated ART in Tororo, Uganda. CD4 counts, CD4 percentages, and viral load (VL) were examined at 6-monthly intervals. Various definitions of immunologic failure were examined to identify individuals with VLs $ 50, $ 500, $ 1000, or $ 5000 copies per milliliter at 6, 12, and 18 months after treatment initiation. Results: One thousand sixty-three ART-naive persons initiated ART. The proportion of individuals with virologic failure ranged between 1.5% and 16.4% for each time point. The proportion with no increase in CD4 count from baseline did not differ between those with suppressed or unsuppressed VLs at 6, 18, and 24 months after ART initiation. No increase in CD4 cell counts at 6 months had a sensitivity of 0.04 [95% confidence interval (CI) 0.00 to 0.10] and a positive predictive value of 0.03 (95% CI 0.00 to 0.09) for identifying individuals with VL $ 500 copies per milliliter at 6 months. The best measure identified was an absolute CD4 cell count , 125 cells per microliter at 21 months for predicting VL $ 500 copies per milliliter at 18 months which had a sensitivity of 0.13 (95% CI 0.01 to 0.21) and a positive predictive value of 0.29 (95% CI 0.10 to 0.44). Conclusions: CD4 cell count monitoring does not accurately identify individuals with virologic failure among patients taking ART. Key Words: Africa, antiretroviral therapy, CD4 cell count, virologic suppression ( J Acquir Immune Defic Syndr 2008;49:477–484) INTRODUCTION Treatment guidelines from the World Health Organization (WHO) regarding the use of antiretroviral therapy (ART) in resource-limited settings recommend the use of CD4 + T-lymphocyte (CD4) counts to monitor response to therapy in programs where HIV-1 viral load (VL) testing is not available. 1 Consequently, CD4 cell counts have become the most common laboratory method for evaluating eligibility for ART and monitoring response to treatment in such settings. The WHO guidelines recommend a change in drug regimen for individuals on ART who have a return of CD4 cell counts to pretherapy levels or a $ 50% decrease in CD4 cell counts from peak levels, both in the absence of intercurrent infections. The large majority of HIV-infected individuals will achieve virologic suppression in response to ART within the first year of treatment 2,3,4 ; therefore, monitoring ART response is used...
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- Fall '10
- Antiretroviral drug, VL, CD4 cell count, Acquir Immune Defic