title: Discordant Treatment Responses to Combination Antiretroviral Therapy in Rwanda: A Prospective Cohort Study.
abstract: BACKGROUND
  Some antiretroviral therapy naïve patients starting combination antiretroviral therapy (cART) experience a limited CD4 count rise despite virological suppression, or vice versa. We assessed the prevalence and determinants of discordant treatment responses in a Rwandan cohort.
  
  
  METHODS
  A discordant immunological cART response was defined as an increase of <100 CD4 cells/mm3 at 12 months compared to baseline despite virological suppression (viral load [VL] <40 copies/mL). A discordant virological cART response was defined as detectable VL at 12 months with an increase in CD4 count ≥100 cells/mm3. The prevalence of, and independent predictors for these two types of discordant responses were analysed in two cohorts nested in a 12-month prospective study of cART-naïve HIV patients treated at nine rural health facilities in two regions in Rwanda.
  
  
  RESULTS
  Among 382 patients with an undetectable VL at 12 months, 112 (29%) had a CD4 rise of <100 cells/mm3. Age ≥35 years and longer travel to the clinic were independent determinants of an immunological discordant response, but sex, baseline CD4 count, body mass index and WHO HIV clinical stage were not. Among 326 patients with a CD4 rise of ≥100 cells/mm3, 56 (17%) had a detectable viral load at 12 months. Male sex was associated with a virological discordant treatment response (P = 0.05), but age, baseline CD4 count, BMI, WHO HIV clinical stage, and travel time to the clinic were not.
  
  
  CONCLUSIONS
  Discordant treatment responses were common in cART-naïve HIV patients in Rwanda. Small CD4 increases could be misinterpreted as a (virological) treatment failure and lead to unnecessary treatment changes.
authors.affiliation: INTERACT, CPCD, PO Box 2181, Kigali, Rwanda.
authors.forename: Felix R
authors.initials: FR
authors.lastname: Kayigamba
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America.|Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Molly F
authors.initials: MF
authors.lastname: Franke
authors.affiliation: Royal Tropical Institute, KIT Biomedical Research, Amsterdam, the Netherlands.
authors.forename: Mirjam I
authors.initials: MI
authors.lastname: Bakker
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America.
authors.forename: Carly A
authors.initials: CA
authors.lastname: Rodriguez
authors.affiliation: INTERACT, CPCD, PO Box 2181, Kigali, Rwanda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Bagiruwigize
authors.affiliation: Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, the Netherlands.|Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center (AMC), Amsterdam, the Netherlands.
authors.forename: Ferdinand Wnm
authors.initials: FW
authors.lastname: Wit
authors.affiliation: Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Rich
authors.affiliation: Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, the Netherlands.|Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center (AMC), Amsterdam, the Netherlands.|Public Health Service of Amsterdam (GGD), Amsterdam, the Netherlands.
authors.forename: Maarten F
authors.initials: MF
authors.lastname: Schim van der Loeff
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology* / Q000821:virology; D015497:HIV-1 / Q000187:drug effects / Q000472:pathogenicity; D006801:Humans; D008297:Male; D008875:Middle Aged; D012432:Rwanda; D017211:Treatment Failure; D019562:Viral Load / Q000187:drug effects
chemical_list: D019380:Anti-HIV Agents