Mortality associated with discordant responses to antiretroviral therapy in resource-constrained settings.
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.
Tuboi
Suely Hiromi
SH
Departamento de Epidemiologia e Bioestatística, Universidade Federal Fluminense, Niterói, Brazil.
Pacheco
Antonio Guilherme
AG
Harrison
Lee H
LH
Stone
Roslyn A
RA
May
Margaret
M
Brinkhof
Martin W G
MW
Dabis
François
F
Egger
Matthias
M
Nash
Denis
D
Bangsberg
David
D
Braitstein
Paula
P
Yiannoutsos
Constantin T
CT
Wood
Robin
R
Sprinz
Eduardo
E
Schechter
Mauro
M
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
D019380:Anti-HIV Agents