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Excellent outcomes among people starting HIV therapy at high CD4 counts in Uganda
Michael Carter, 2014-08-08 08:20:00
People in Uganda starting
antiretroviral therapy (ART) with higher CD4 counts can achieve
excellent outcomes, investigators report in the online edition of AIDS. Asymptomatic adults who started
therapy with a CD4 count above 350 cells/mm3 were monitored for
twelve months. Almost all were retained in care, 97% achieved an undetectable
viral load, adherence was excellent and toxicities and side-effects were rare. The participants in the study received stream-lined, nurse-led care.
challenge current concerns that individuals with high CD4+ cell
count may not desire or adhere well to ART, or be able to achieve robust
virologic suppression,” write the authors.
Access to ART is
being rapidly scaled-up in resource-limited settings and the World Health
Organization (WHO) estimates that, in 2013, some 9.7 million people were in
receipt of HIV therapy.
higher CD4 counts – above 350 cells/mm3 – have only recently become
eligible for ART in sub-Saharan Africa. Some researchers have expressed concern
that people in good health will not adhere to their treatment or will drop out of
care, meaning that many would not achieve virologic suppression.
To settle this
question, investigators designed a prospective, open-label study involving
asymptomatic, ART-naive adults with CD4 counts above 350 cells/mm3. They
started therapy with a combination of emtricitabine/tenofovir and efavirenz
(ritonavir/lopinavir was available for people unable to tolerate efavirenz).
The investigators reported on retention in care over 48 weeks, rates of
virological suppression (viral load below 400 copies/ml) at weeks 24 and 48,
adherence (self-reported three-day recall) and rates of toxicities and
side-effects. Care was nurse-led and support was also offered using mobile
A total of 197 people were recruited to the study between 2011 and 2012. CD4 count at baseline
was high at a median of 564 cells/mm3 and median viral load was
retention rate was 98% at week 48. Rates of virological suppression at weeks 24
and 48 were 96% and 97%, respectively.
excellent, with participants reporting taking all their doses in the preceding
three days at 98% of study visits.
Treatment had good
safety and tolerability. There were 22 grade 3 or 4 laboratory abnormalities,
the most common being asymptomatic neutropenia. Creatinine elevations were
observed in two people, but these resolved after tenofovir was discontinued.
Non-routine use of
the services outside scheduled visits was rare. There were a
total of 384 non-routine visits, most were unscheduled drop-in visits for minor
skin conditions, respiratory complaints or gastrointestinal symptoms.
The average length
of clinic visits was 25 to 54 minutes.
excellent ART outcomes in Ugandan patients with CD4+ cell counts
above 350 cells/mm3 using a nurse-driven care model,” conclude the
authors. “Further research will be needed to demonstrate the long-term
durability of streamlined care models for high CD4+ cell populations
who are expected to preserve health and high CD4+ cell counts during