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Early immunologic response and subsequent survival among malnourished adults receiving antiretroviral therapy in Urban Zambia

Koethe, John Ra,b; Limbada, Mohammed Ia; Giganti, Mark Ja,c; Nyirenda, Christopher Kd; Mulenga, Lloyda; Wester, C Williamb; Chi, Benjamin Ha,c; Stringer, Jeffrey Sa,c

doi: 10.1097/QAD.0b013e32833b784a
Epidemiology and Social: CONCISE COMMUNICATION

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.

Design: 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 ≥18.5 kg/m2), 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/μl. 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/μl increase in the first 6 months of ART. A CD4+ cell count increase of at least 100 cells/μl 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.

aCentre for Infectious Disease Research in Zambia, Lusaka, Zambia

bVanderbilt University School of Medicine, Division of Infectious Diseases, Nashville, Tennessee, USA

cDepartment of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama, USA

dUniversity Teaching Hospital, Lusaka, Zambia.

Received 9 March, 2010

Revised 16 April, 2010

Accepted 28 April, 2010

Correspondence to John R. Koethe, MD, Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, A2200-MCN, 1161 21st Avenue South, Nashville, TN 37232-2582, USA. Tel: +1 615 322 6928; fax: +1 615 343 6160; e-mail:

Sources of funding: Investigator salary or trainee support is provided by the Fogarty International Center (R24-TW007988, K01-TW06670) and a Clinical Scientist Development Award from the Doris Duke Charitable Foundation (2007061). No conflicts of interest were reported by any author.

© 2010 Lippincott Williams & Wilkins, Inc.