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Early Initiation of Antiretroviral Therapy and Low Immune Activation Level would Reduce Mortality in African People Living with HIV with High CD4 Cell Count Levels.

The long-term outcome of ART-naïve people living with HIV (PLHIV) with baseline CD4 count ?350 is not well described. We aimed to analyze mortality in an ART-naïve West African cohort of PLHIV followed for 18 years according to the effects of CD4 cell count stratum (350-499 versus ?500), HIV serotype and immune activation (IA). The cumulative incidences of death in this cohort were calculated using competing risk estimators; treating ART initiation as a competing event for death. To evaluate the effect of baseline CD4 cell counts, HIV serotype and beta 2 microglobulin (?2m) level on mortality with the presence of competing event, we used competing risks regression models to calculate the corresponding sub-distribution hazard ratios (sHR) with adjustment for confounding bias. During 18 years of follow up, the 908 patients realized 5367 clinical visits totaling 2138.1 person-years (PY) of exposure time. A total of 160 deaths was recorded and 67 patients initiated ART; resulting in a mortality incidence rate of 7.5/100 PY. After adjustment, baseline CD4 cell counts between 350 and 499/µL was associated with a 49% increase in mortality compared to baseline CD4 cell counts ?500/µL (adjusted sHR (asHR) = 1.49; 95% CI = 1.07-2.07). HIV serotype was also associated with mortality (the asHR were respectively 1.66 (95% CI = 1.14-2.43) and 2.15 (95% CI = 1.25-3.73) for HIV-1 and HIV-1 + HIV-2 dual infection (HIV-D) compared to HIV-2 infection). Mortality was also associated with ?2m level (?2.85 mg/L compared to <2.85 mg/L) with an asHR = 3.26 (95%CI = 2.03-5.25). Our study provides a picture of real-life long-term differences in mortality in a context of high prevalence of HIV and immune activation. It confirms the benefits of early initiation of ART found in randomized clinical trials (RCT) and suggests a potential benefit of the reduction of IA level in African PLHIV .

Auteur(s) : 33. Diouf A, Trottier H, Thomas G, Seck A, Thiam M, Sangaré MN, Mboup S, NguyenV-K and Jaye A
Pages : 17-38
Année de publication : 2019
Revue : International Journal of AIDS
N° de volume : 2
Type : Article
Mise en ligne par : DIOUF Assane