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Even at High CD4-Cell Counts, Mortality Rates Are High in Untreated HIV Infection

An observational study from Côte d'Ivoire supports earlier treatment initiation, particularly in sub-Saharan Africa.

Only very limited data exist on causes of death among untreated HIV-infected individuals in sub-Saharan Africa, especially those with high CD4-cell counts. Such data could be extremely relevant for discussions on when to start antiretroviral therapy (ART), given that some of the main arguments revolve around whether ART prevents morbidity and mortality in less immunocompromised individuals.

In a new report on this topic, investigators describe morbidity and mortality across CD4-cell count strata for two large cohorts of patients in Côte d'Ivoire. Follow-up time is included only from when patients were receiving prophylactic cotrimoxazole but had not yet started ART.

A total of 860 patients (94% positive for HIV-1, 1% for HIV-2, and 5% for both) were followed for an average of 36 months. As expected, the rate of AIDS or death was inversely proportional to CD4-cell count. Of particular note, death rates were substantial even in the CD4-cell count strata for which ART is not presently recommended by the WHO (1.6, 0.6, and 0.3 deaths/100 person-years in the 350–500, 500–649, and >650 cells/mm³ strata, respectively). The most frequent severe diseases in patients with higher CD4-cell counts were tuberculosis and invasive bacterial illnesses.

Comment: The event rates cited in this study likely underestimate the true figures for sub-Saharan Africa, given that cohort participants had prompt access to hospital treatment, which is not the rule for the population at large. The death rate among patients with CD4 counts of 350 to 500 cells/mm³ (1.6 deaths/100 person-years) was several-fold higher than the rates previously reported for patients with the same CD4-cell counts in developed countries (0.3 deaths/100 person-years in the UK CHIC study) and for the overall adult population of sub-Saharan Africa (0.6 deaths/100 person-years). These data suggest that earlier ART initiation might have a greater effect on morbidity and mortality in sub-Saharan Africa than in developed countries, an observation that could have major implications for the design of clinical trials and for the development of region-specific treatment guidelines.

— Mauro Schechter, MD, PhD

Dr. Schechter is a Professor of Infectious Diseases at Universidade Federal do Rio de Janeiro, Head of the AIDS Research Laboratory at Hospital Universitario Clementino Fraga Filho, and Principal Investigator of Projeto Praça Onze at Hospital Escola São Francisco de Assis in Brazil. He reports no conflicts of interest.

Published in Journal Watch HIV/AIDS Clinical Care January 13, 2012

Citation(s):

Anglaret X et al. AIDS and non-AIDS morbidity and mortality across the spectrum of CD4 cell counts in HIV-infected adults before starting antiretroviral therapy in Côte d'Ivoire. Clin Infect Dis 2011 Dec 14; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/cir898)

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