title: Early immunologic response and subsequent survival among malnourished adults receiving antiretroviral therapy in Urban Zambia.
abstract: OBJECTIVE
  To evaluate the relationship between early CD4(+) lymphocyte recovery on antiretroviral therapy (ART) and subsequent survival among low body mass index (BMI) HIV-1-infected adults.
  
  
  METHODS
  Retrospective analysis of a large programmatic cohort in Lusaka, Zambia.
  
  
  METHODS
  We evaluated ART-treated adults enrolled in care for more than 6 months. We stratified this study population according to World Health Organization (WHO) malnutrition criteria: normal (BMI >or=18.5 kg/m(2)), mild (17.00-18.49), moderate (16.00-16.99), and severe (<16.0). We used Cox proportional hazards regression to estimate the subsequent risk of death associated with absolute CD4(+) cell count change over the first 6 months on ART. To account for effect modification associated with baseline CD4(+) cell count, a weighted summary measure was calculated.
  
  
  RESULTS
  From May 2004 to February 2009, 56,612 patients initiated ART at Lusaka district clinics; of these, 33 097 (58%) were included in this analysis. The median change in 0-6 month CD4(+) cell count in each baseline BMI strata varied from 127 to 131 cells/microl. There was a statistically significant, inverse association between baseline BMI and the post 6-month hazard for mortality only among those patients with less than 100 cells/microl increase in the first 6 months of ART. A CD4(+) cell count increase of at least 100 cells/microl over the first 6 months of ART was not associated with a higher hazard for mortality, regardless of baseline BMI.
  
  
  CONCLUSIONS
  Low baseline BMI and attenuated CD4(+) cell count response at 6 months had a compounding, negative impact on post 6-month survival. Specific guidelines for monitoring ART response using immunologic criteria may be warranted for low BMI patients.
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. john.r.koethe@vanderbilt.edu
authors.forename: John R
authors.initials: JR
authors.lastname: Koethe
authors.forename: Mohammed I
authors.initials: MI
authors.lastname: Limbada
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Giganti
authors.forename: Christopher K
authors.initials: CK
authors.lastname: Nyirenda
authors.forename: Lloyd
authors.initials: L
authors.lastname: Mulenga
authors.forename: C William
authors.initials: CW
authors.lastname: Wester
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Stringer
mesh_terms: D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D015992:Body Mass Index; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology* / Q000401:mortality; D015497:HIV-1; D006801:Humans; D008297:Male; D044342:Malnutrition / Q000188:drug therapy / Q000276:immunology* / Q000401:mortality; D012189:Retrospective Studies; D014504:Urban Health; D055815:Young Adult; D015024:Zambia / Q000453:epidemiology