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A study on HIV-infected individuals who reported CD4+ cell count below 100 cells/μl multiple times after more than 6 months of antiretroviral therapy at the apex tertiary referral hospital of India


1 Department of Microbiology, National HIV Reference Laboratory, All India Institute of Medical Sciences, New Delhi, India
2 ART Clinic, Department of Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Submission08-Nov-2021
Date of Decision14-Mar-2022
Date of Acceptance15-Mar-2022
Date of Web Publication01-Aug-2022

Correspondence Address:
Bimal Kumar Das,
National HIV Reference Laboratory, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijstd.ijstd_103_21



How to cite this URL:
Maurya SP, Singh R, Sinha S, Gautam H, Das BK. A study on HIV-infected individuals who reported CD4+ cell count below 100 cells/μl multiple times after more than 6 months of antiretroviral therapy at the apex tertiary referral hospital of India. Indian J Sex Transm Dis [Epub ahead of print] [cited 2022 Oct 5]. Available from: https://www.ijstd.org/preprintarticle.asp?id=352911

Sir,

CD4+ cell count is a reliable predictor of the risk of disease and death among HIV-infected individuals. CD4+ cell count below 100 cells/μl multiple times despite antiretroviral therapy (ART) is considered immunological failure to ART.[1] A 6-month time period after initiation of ART regimen is considered sufficient to lift CD4+ cell count to normal levels.[2] Recognizing the significance of such cases, we analyzed data of HIV-infected individuals who reported two or more CD4+ cell count below 100/μl after >6 months of first-line ART during 2009–2018 (10-year study group). COVID-19 period was excluded as it disrupted HIV testing and was associated with reduced CD4+ cell count.[3],[4]

12.3% of ART-treated HIV-positive individuals reported two or more CD4+ cell count <100 cells/μl after >6 months of first-line ART. Such cases have gradually increased since 2012. Compared with control group (i.e., individuals with last CD+ Cell count >500 cells/μl after >6 months of first-line ART during the same period), there were significantly higher proportionate of individuals in age groups 30–40 years, 40–50 years, 50–60 years, and >60 years in study group (P < 0.0001, >30 years vs. <30 years; Chi-square test) [Table 1]. There were significantly higher numbers of males and lower females in study group than control group (P < 0.0001; Chi-square test). There was significantly higher percentage of individuals with monthly income below Indian rupee (INR) 10,000 in study group in comparison to control group (P = 0.05, INR <10,000 vs. INR >10,000; Chi-square test). Study group had 7.5 times more individuals with baseline (i.e., at the time of HIV confirmation) CD4+ cell count <100 cells/μl (P < 0.0001; Chi-square test) and nine times less individuals with baseline CD4+ cell count >500 cells/μl (P < 0.0001; Chi-square test) than control group. Only 9.7% of individuals in study group could reach last CD4+ count >500 cells/μl, 37.5% had last known CD4+ count >200 cells/μl, 19.1% had last known CD4+ count 100–200 cells/μl, and 43.0% reported last known CD4+ count <100 cells/μl. There was nonsignificant difference in the existence of tuberculosis in study group and control group (P = 0.21, HIV-TB vs. Non-HIV-TB; Chi-square test); although study group had higher tuberculosis incidence than control group (7.2% vs. 5.4%) [Table 1]. The death rate in study group was 14.9% and it was significantly higher in comparison to control group (1.4%) (P < 0.0001, died vs. alive; Chi-square test) [Table 1]. Among those who died in the study group, only 1.7% had CD4+ cell count >500 cells/μl at the time of HIV confirmation.
Table 1: Factors associated with CD4+ cell count <100 cells/μl on multiple occasions after >6 months first-line antiretroviral therapy treatment (study group), the control group included those with current CD4+ cell count >500 cells/μl after >6 months of first-line antiretroviral therapy treatment

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CD4+ cell count at the time of HIV confirmation is the strongest predictor of recovery in CD4+ counts following initiation of ART.[5] Starting ART at CD4+ cell count >500 cells/μl and within 4 months of HIV seroconversion is associated with a greater long-term increase in CD4+ count.[5] ART is now initiated as soon as HIV infection is diagnosed, however, late diagnosis of HIV infection complicates CD4+ cells recovery. Awareness campaigns regarding “health hazards in late ART initiation” are needed to motivate people for early HIV testing and ART initiation at healthy baseline CD4+ cell count.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection. 2nd ed. Switzerland: World Health Organization; 2016. Available from: https://apps.who.int/iris/bitstream/handle/10665/208825/9789241549684_eng.pdf?sequence=1. [Last accessed on 2021 Nov 07].  Back to cited text no. 1
    
2.
World Health Organization. Antiretroviral Therapy for HIV Infection in Adults and Adolescents. Recommendations for a Public Health Approach. Geneva, Switzerland: WHO; 2010. Available from: https://apps.who.int/iris/bitstream/handle/10665/44379/9789241599764_eng.pdf?sequence=1. [Last accessed on 2021 Nov 07].  Back to cited text no. 2
    
3.
Maurya SP, Sharma A, Singh R, Gautam H, Das BK. HIV testing & diagnosis in 2020 at the apex tertiary referral hospital of India: Impact of COVID-19 pandemic. AIDS Care. 2021 Sep 8;1-4. doi: 10.1080/09540121.2021.1975631. Online ahead of print.  Back to cited text no. 3
    
4.
Xu B, Fan CY, Wang AL, Zou YL, Yu YH, He C, et al. Suppressed T cell-mediated immunity in patients with COVID-19: A clinical retrospective study in Wuhan, China. J Infect 2020;81:e51-60.  Back to cited text no. 4
    
5.
Stirrup OT, Copas AJ, Phillips AN, Gill MJ, Geskus RB, Touloumi G, et al. Predictors of CD4 cell recovery following initiation of antiretroviral therapy among HIV-1 positive patients with well-estimated dates of seroconversion. HIV Med 2018;19:184-94.  Back to cited text no. 5
    



 
 
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