Share this article on:

Initiating antiretroviral therapy when presenting with higher CD4 cell counts results in reduced loss to follow-up in a resource-limited setting

Clouse, Kate; Pettifor, Audrey; Maskew, Mhairi; Bassett, Jean; Van Rie, Annelies; Gay, Cynthia; Behets, Frieda; Sanne, Ian; Fox, Matthew P.

doi: 10.1097/QAD.0b013e32835c12f9
Epidemiology and Social: CONCISE COMMUNICATION

Objective: In August 2011, South Africa expanded its adult antiretroviral therapy (ART) guidelines to allow treatment initiation at CD4 cell values 350 cells/μl or less. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up.

Design: An observational cohort study.

Methods: We analyzed routine data of 1430 adult patients initiating ART from April to December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 cell count 350 cells/μl or less since 2010. We compared loss to follow-up (≥3 months late for the last scheduled visit), death, and incident tuberculosis within 1 year of ART initiation for those initiating at CD4 cell values 200 or less versus 201–350 cells/μl.

Results: Half (52.0%) of patients presented in the lower CD4 cell group [≤200 cells/μl, median: 105 cells/μl, interquartile range (IQR): 55–154] and initiated ART, and 48.0% in the higher group (CD4 cell count 201–350 cells/μl, median: 268 cells/μl, IQR: 239–307). The proportion of women and pregnant women was greater in the high CD4 cell group; the lower CD4 cell group included more patients with prevalent tuberculosis. Among men and nonpregnant women, initiating at 201–350 cells/μl was associated with 26–42% reduced loss to follow-up compared to those initiating 200 cells/μl or less. We found no CD4 cell effect among pregnant women. Risk of mortality [adjusted hazard ratio (aHR) 0.34, 95% confidence interval (CI) 0.13–0.84] and incident tuberculosis (aHR 0.44, 95% CI 0.23–0.85) was lower among the higher CD4 cell group.

Conclusion: This is one of the first studies from a routine clinical setting to demonstrate South Africa's 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition.

aHealth Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

bDepartment of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

cWitkoppen Health and Welfare Centre, Johannesburg, South Africa

dSchool of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

eCenter for Global Health and Development

fDepartment of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USA.

Correspondence to Kate Clouse, Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC 27599-7435, USA. E-mail:

Received 28 August, 2012

Revised 16 October, 2012

Accepted 30 October, 2012

Copyright © 2013 Wolters Kluwer Health, Inc.