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Program-level determinants of low CD4 count ART initiation in cohorts of persons aged ≥ 6 years initiating ART in 8 sub-Saharan African countries
Presented by Denis Nash (United States).
D. Nash1, Y. Wu1, S. Gandhi2, M. Manyasha3, R. Ntumy3, B. Elul1, W. El Sadr1, for the International Center for AIDS Care and Treatment Programs (ICAP)
1Columbia University - Mailman School of Public Health, International Center for AIDS Care and Treatment Programs (ICAP), New York, United States, 2Columbia University College of Physicians and Surgeons, Division of Infectious Diseases, New York, United States, 3International Center for AIDS Care and Treatment Programs (ICAP), Lesotho, Maseru, Lesotho
Background: Despite guidelines recommending earlier initiation of antiretroviral therapy (ART), many patients initiate ART in the advanced stages of HIV disease. While low CD4 count at ART initiation has been identified as a key individual-level risk factor for early mortality, little is known about program-level factors (e.g., approaches to identifying, enrolling, managing, and retaining patients) that may influence the CD4 count at ART initiation.
Methods: We used quarterly PEPFAR cohort-level aggregate indicator data on the median CD4 count at ART initiation from 248 sites in 8 sub-Saharan African countries (Ethiopia, Kenya, Lesotho, Mozambique, Nigeria, Rwanda, South Africa, Tanzania) where a total of 1,438 cohorts (representing 103,124 patients) initiated ART during 1/2005-10/2008. Cohorts were comprised of patients who initiated ART at a given site each quarter. Cohort information was combined with contemporaneous program-level data from semi-annual facility surveys. Cohorts with median CD4 counts < 109 cells/µL (the lowest quartile) were classified as having low CD4 counts at ART initiation. We used generalized linear mixed modeling to examine factors associated with low CD4 count among cohorts of patients initiating ART.
Results: The median CD4 count for all of the cohorts was 135 cells/µL (IQR=109-175), and increased steadily from 115 to 140 cells/µL during 1/2005-10/2008. The median cohort size was 43 new ART patients per site per quarter (IQR=20-88). After controlling for calendar time, cohort size, and country, program level factors independently associated with low median CD4 counts included: being unaffiliated with a PMTCT program (OR=6.0, 95%CI=1.5-26), lack of outreach services for pre-ART patients who miss visits (OR=2.1, 95%CI=1.4-3.2), and program setting (ORurban vs. rural=1.7, 95%CI=1.2-2.5).
Conclusions: On average, patients initiating ART more recently did so at less advanced stages of HIV disease than those who initiated in earlier phases of scale-up. Program-level factors may be important modifiable, structural determinants CD4 count at ART initiation.
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