title: Mortality associated with discordant responses to antiretroviral therapy in resource-constrained settings.
abstract: OBJECTIVE
  We assessed mortality associated with immunologic and virologic patterns of response at 6 months of highly active antiretroviral therapy (HAART) in HIV-infected individuals from resource-limited countries in Africa and South America.
  
  
  METHODS
  Patients who initiated HAART between 1996 and 2007, aged 16 years or older, and had at least 1 measurement (HIV-1 RNA plasma viral load or CD4 cell count) at 6 months of therapy (3-9 month window) were included. Therapy response was categorized as complete, discordant (virologic only or immunologic only), and absent. Associations between 6-month response to therapy and all-cause mortality were assessed by Cox proportional hazards regression. Robust standard errors were calculated to account for intrasite correlation.
  
  
  RESULTS
  A total of 7160 patients, corresponding to 15,107 person-years, were analyzed. In multivariable analysis adjusted for age at HAART initiation, baseline clinical stage and CD4 cell count, year of HAART initiation, clinic, occurrence of an AIDS-defining condition within the first 6 months of treatment, and discordant and absent responses were associated with increased risk of death.
  
  
  CONCLUSIONS
  Similar to reports from high-income countries, discordant immunologic and virologic responses were associated with intermediate risk of death compared with complete and no response in this large cohort of HIV-1 patients from resource-limited countries. Our results support a recommendation for wider availability of plasma viral load testing to monitor antiretroviral therapy in these settings.
authors.affiliation: Departamento de Epidemiologia e Bioestatística, Universidade Federal Fluminense, Niterói, Brazil.
authors.forename: Suely Hiromi
authors.initials: SH
authors.lastname: Tuboi
authors.forename: Antonio Guilherme
authors.initials: AG
authors.lastname: Pacheco
authors.forename: Lee H
authors.initials: LH
authors.lastname: Harrison
authors.forename: Roslyn A
authors.initials: RA
authors.lastname: Stone
authors.forename: Margaret
authors.initials: M
authors.lastname: May
authors.forename: Martin W G
authors.initials: MW
authors.lastname: Brinkhof
authors.forename: François
authors.initials: F
authors.lastname: Dabis
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.forename: Denis
authors.initials: D
authors.lastname: Nash
authors.forename: David
authors.initials: D
authors.lastname: Bangsberg
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: Constantin T
authors.initials: CT
authors.lastname: Yiannoutsos
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Eduardo
authors.initials: E
authors.lastname: Sprinz
authors.forename: Mauro
authors.initials: M
authors.lastname: Schechter
mesh_terms: D000328:Adult; D000349:Africa / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000401:mortality; D018791:CD4 Lymphocyte Count; D016903:Drug Monitoring; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality*; D015497:HIV-1; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D013020:South America / Q000453:epidemiology; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents