Correspondence Address:
Dr. Bimal Kumar Das
National HIV Reference Laboratory, All India Institute of Medical Sciences, New Delhi
India

Full Text

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}

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.

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Conflicts of interest

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References