Τίτλος:
Comparison of dynamic monitoring strategies based on CD4 cell counts in
virally suppressed, HIV-positive individuals on combination
antiretroviral therapy in high-income countries: a prospective,
observational study
Περίληψη:
Background Clinical guidelines vary with respect to the optimal
monitoring frequency of HIV-positive individuals. We compared dynamic
monitoring strategies based on time-varying CD4 cell counts in
virologically suppressed HIV-positive individuals.
Methods In this observational study, we used data from prospective
studies of HIV-positive individuals in Europe (France, Greece, the
Netherlands, Spain, Switzerland, and the UK) and North and South America
(Brazil, Canada, and the USA) in The HIV-CAUSAL Collaboration and The
Centers for AIDS Research Network of Integrated Clinical Systems. We
compared three monitoring strategies that differ in the threshold used
to measure CD4 cell count and HIV RNA viral load every 3-6 months (when
below the threshold) or every 9-12 months (when above the threshold).
The strategies were defined by the threshold CD4 counts of 200 cells per
mu L, 350 cells per mu L, and 500 cells per mu L. Using inverse
probability weighting to adjust for baseline and time-varying
confounders, we estimated hazard ratios (HRs) of death and of
AIDS-defining illness or death, risk ratios of virological failure, and
mean differences in CD4 cell count.
Findings 47 635 individuals initiated an antiretroviral therapy regimen
between Jan 1, 2000, and Jan 9, 2015, and met the eligibility criteria
for inclusion in our study. During follow-up, CD4 cell count was
measured on average every 4.0 months and viral load every 3.8 months.
464 individuals died (107 in threshold 200 strategy, 157 in threshold
350, and 200 in threshold 500) and 1091 had AIDS-defining illnesses or
died (267 in threshold 200 strategy, 365 in threshold 350, and 459 in
threshold 500). Compared with threshold 500, the mortality HR was 1.05
(95% CI 0.86-1.29) for threshold 200 and 1.02 (0.91.1.14) for threshold
350. Corresponding estimates for death or AIDS-defining illness were
1.08 (0.95-1.22) for threshold 200 and 1.03 (0.96-1.12) for threshold
350. Compared with threshold 500, the 24 month risk ratios of
virological failure (viral load more than 200 copies per mL) were 2.01
(1.17-3.43) for threshold 200 and 1.24 (0.89-1.73) for threshold 350,
and 24 month mean CD4 cell count differences were 0.4 (-25.5 to 26.3)
cells per mu L for threshold 200 and -3.5 (-16.0 to 8.9) cells per mu L
for threshold 350.
Interpretation Decreasing monitoring to annually when CD4 count is
higher than 200 cells per mu L compared with higher than 500 cells per
mu L does not worsen the short-term clinical and immunological outcomes
of virally suppressed HIV-positive individuals. However, more frequent
virological monitoring might be necessary to reduce the risk of
virological failure. Further follow-up studies are needed to establish
the long-term safety of these strategies.
Συγγραφείς:
Caniglia, Ellen C.
Cain, Lauren E.
Sabin, Caroline A. and
Robins, James M.
Logan, Roger
Abgrall, Sophie
Mugavero,
Michael J.
Hernandez-Diaz, Sonia
Meyer, Laurence
Seng,
Remonie
Drozd, Daniel R.
Seage, III, George R.
Bonnet,
Fabrice
Dabis, Francois
Moore, Richard D.
Reiss, Peter and
van Sighem, Ard
Mathews, William C.
del Amo, Julia
Moreno,
Santiago
Deeks, Steven G.
Muga, Roberto
Boswell, Stephen L.
and Ferrer, Elena
Eron, Joseph J.
Napravnik, Sonia
Jose,
Sophie
Phillips, Andrew
Justice, Amy C.
Tate, Janet P. and
Gill, John
Pacheco, Antonio
Veloso, Valdilea G.
Bucher,
Heiner C.
Egger, Matthias
Furrer, Hansjakob
Porter, Kholoud
and Touloumi, Giota
Crane, Heidi
Miro, Jose M.
Sterne,
Jonathan A.
Costagliola, Dominique
Saag, Michael
Hernan,
Miguel A.
HIV-CAUSAL Collaboration
Ctr AIDS Res Network Integra
