Effect of First-Line Antiretroviral Treatment in HIV- Positive Patients on Cd4 Cell Count Response in Boru Meda Hospital, Amhara Regional State, Deisse, Ethiopia, 2013-2018
Abstract
Background: In limited resource countries, the effectiveness
of first-line antiretroviral treatment in HIV-positive patients could be
measured by its strong predictor, the CD4 count for the initiation of
antiretroviral therapy and proper management of disease progress. Even
though, in addition to HIV, there are many factors which can influence
the CD4 cell count considered to be constant. Methods: A retrospective
cohort study was conducted to examine the response of first-line
antiretroviral treatment on CD4 count in HIV-positive patients at 0, 6,
12 and 24 months, who enrolled in the first month of 2013 and followed
up to begining-2018.The covariance components model was employed to
determine the CD4 count changes over time. Results: A total of 320 ART
attendants were used to analyze their data. The majority 294(92.4%) of
the respondents were started AZT based ART regimens, but there was no a
significance difference among ART regimens for CD4 cell count.
The mean baseline of CD4 cell count (166 cells/ mm3) was positive associated (p<0.001) with CD4 count increment at time of follow ups and was increased to 274 cells/mm3
significantly (p<0.001) at six months of initiation of ART. Working
functional status and younger age, also contribute for CD4 count
significant change. Conclusion: The change in CD4 count was high at the
first 6 month than 12 and 24 month. All ART regimens without
significance difference that increased mean CD4 count at the study
period. Hence, it can be concluded that ART is effective enough in
improving the immune system and slowing the progression of HIV infection
to AIDS.
Introduction
Human Immunodeficiency Virus (HIV) destroys specific cells of the
body that defend the body against diseases are called CD4 cells [1,2].
HIV-positive patients with optimal antiretroviral therapy in the first
6-12 months in ARV naive and adherent patient with drug susceptible
virus, CD4 counts are increase by > 100 cells/mm3.
Immunologic failure is indicated by a fall in CD4 counts higher than 50%
from the peak value or a return to, or below, the pre-therapy baseline,
or by persistent CD4 < 100 cells/mm3 [3]. The CD4+ cell
count thresholds for ART initiation were recently raised 350 to500
cells/ml in the United States, while from 200 to350 cells/ml in mid- and
low-income countries [4]. The introduction of ART as a modality of
treatment in HIV positives has resulted in a dramatic decrease in AIDS
related morbidity and mortality and a great improvement in CD4 count of
patients [5]. The aims of this study were to examine the relationship
between patterns in CD4 count after initiation of combination
antiretroviral treatment in HIV-infected patients.
Methods
Study Design and Period
A retrospective cohort study was conducted to assess the effect of
ART on CD4 count among adult ART users enrolled in the first month of
2013 and followed up to begining-2018.
Study Area and Population
The study was conducted at Bour meda Hospital (BMH) ART clinic,
located in Dessie town, Amhara regional state, which is far 411 km, away
from Addis Ababa the capital city of Ethiopia. The hospital gives ART
initiation to the newly diagnosed HIV-infected patients after HIV
testing with follow up treatment. The study population included HIV
positive adults who initiated current first line ART treatment in the
BMH.
Sample Size and Sampling Procedure
All HIV positive adults who initiated ART in the hospital at study
period and who had a complete CD4 count measurements at 0, 6, 12 and 24
months all were included. Therefore, 320 patients were taken.
Data Collection Procedures
The study completely used secondary data. Therefore, a data
extraction check-list was adopts and modified the routinely collected
data. A baseline WHO stage, functional state, weight and CD4 count data
were identified and collected from the registration documents of ART
attendants which were collected from each patient at the initiation of
ART. Subsequent CD4 count data were also taken from the same sources
that were collected from each patient almost every 6 month. Similarly,
other characteristics, like socio-demographic (sex and age) and initial
regimen were also collected from the registration documents of patients.
The data were entered, cleaned, and analyzed using SPSS version 20
statistical software. The CD4 count measurement just before the
initiation of ART was considered as a covariate so that there should be
at least one CD4 count reading that would be taken as a response
variable after the initiation of ART.
Ethical Considerations
Prior to study initiation, ethical clearance was obtained from Amhara
public health institute. In addition, an official letter was written to
BMH from Amhara Regional Health bureau and also permission was sought
from BMH medical director to conduct the study. The confidentiality of
data collected was maintained by omitting the Name and address of
patient and prescriber.
Result
Socio-demographic, Initial regimens, baseline clinical and
immunological status of the respondents. A total of 320 HIV positive
records were analyzed. The prevalence of age of study participants in
the age group <35 years were 150(47.2%) and more than hafe184 (57.9%)
of them were initiated ART at WHO clinical stage III. Regarding the
baseline CD4 cell count 102(32.1%) of the respondents were <100
cells/mm3. The majority 294(92.4%) of the respondents were
started AZT based ART regimens. More than half of the respondents
198(62.3%) were female and most 246(77.4%) of them were Workable (Tables
1-3) and (Figures 1-5).
Figure 1: Cd4 pattern on ART regimen.
Mean CD4 cell counts: The Mean CD4 cell counts of female at base line
and time of follow up (173.6±99.2, 286.1±158.8, 319.2±174.0 and
375.6±201.0) were higher than male (136.0±85.8, 255.6±126.6, 314.3±172.0
and 353.0±184.0). According to the age group between 46-55 the Mean CD4
cell counts at 24 month was 391.6±278.4 and almost closely similar at
WHO stage III (390.7±202.6)
Discussion
This study was aimed describing that the response of ART to CD4 cell
counts for patients on ART at BMH. In the present study, more than half
of the patients initiating ART 198(62.3%) were females. A similar
finding was reported by Lemma Derseh; from Ethiopia, Felege Hiwot
Referral Hospital who stated ART were more likely to be females [6].
Latin America, sub-Saharan Africa, Asia [7] and South Africa were
similarly reported [8]. In the developing countries females have high
prevalence to HIV infection, due to socially and biologically weaker to
infect by HIV [9]. Other authors reported that females more likely to be
diagnosed for infection earlier, could attend voluntary counseling and
testing [10,11], had also better response to ART [12], repeated-testing,
and acceptance of linkage to HIV-care after a positive result as
compared to males [13-16]. The CD4 count has been commonly used as the
main treatment outcome signs for continuation of ART
The goal of ART is to achieve sustained viral suppression and
increased CD4 counts in individuals on treatment. The responses of ART
to CD4 cell is determine by viral and host factors, in which individuals
having suboptimal increase of CD4 cell count with approximately 15-30%,
there are no compliance to ART [6]. In the present study, there was a
good immune recovery at the six month of therapy. The mean baseline of
CD4 cell count (166 cells/ mm3) was positive associated (p<0.001) with CD4 count at time of follow ups and was increased to 274 cells/mm3
significantly (p<0.001) at six months of imitation of ART. According
to the study in Nepal Public Health Laboratory the baseline CD4 count
was 155cells/ mm3, which increased to 297cells/mm3 significantly higher
than the present study [17]. According to ART management guideline three
or more ART drugs are recommended worldwide for the treatment of HIV+
[7].
In this study, showed that the majority 294(92.4%) of the respondents
were started AZT based ART regimens. Most of ART regimens that increase
mean CD4 cell count at the time of point of follow up, especially at
the first 6 month (minimum 95 cells/mm3;
AZT+3TC+EFV---Maximum 202.5 cells/mm3; AZT+3TC+ABC), but there was no a
significance difference among ART regimens for sustain increasing the
CD4 cell count. Similarly reported by Patel et al. study, both NVP and
EFV at any given point of time there was no significance difference in
the rate of increase of CD4 count [9]. In contrast after 6 months of
therapy there is significant rise of CD4 count in Nevirapine (p <
0.001) regimens than in Efavirenz (p > 0.05) regimens [6]. According
to Baseline WHO clinical stages the majority 184(57.9%) started
treatment in late stages of the disease (stage III). On the other
studies conducted in Addis Ababa, yekatit 12 hospital 465 (52.4%) and
south Africa majority of HIV+ started ART treatment at the stage of III
and IV [6,18].
Regarding baseline functional states were showed that a significance
change on CD4 cell count at each time of follow ups, also this is
supported by other studies done in north- west and eastern Ethiopia
[7,19]. Patients who started ART at working status had a good immune
response in the study period of time than ambulatory/bedridden, similar
finding also reported by other study [7]. The CD4 count measurements
could affect by opportunistic infections at the start of ART and
treatment period over time [20]. There was a significant (p<0.05)
association between Baseline age and Cd4 counts at six month. At older
baseline age the Cd4 count was decreased by -28.269 coefficients as
compared to younger age. Different authors stated that younger age more
reasoned out on CD4 cell recovery [21]. ART treatment response for older
persons was poor [22] and come to the clinic late [23,24]. In contrast,
other authors reported there was no any significance association
between age and CD4 count increment [7,20,21,25,26].
Limitations
In this paper some limitations that should be considered. The study
was retrospective design, so it is difficult to get some relevant
variables full information from record book and patients' card
especially clinical characteristics, nutritional status and educational
status.
Conclusion
This study had shown, higher baseline CD4 count, contributed to great
significant (p<0.001) increment of CD4 count. The change in CD4
count was high at the first 6 month than 12 and 24 month.Working
functional status and younger age, also contribute for CD4 count change.
All ART regimens without significance difference that increased mean
cd4 count at the study period. Hence, it can be concluded that ART is
effective enough in improving the immune system and slowing the
progression of HIV infection to AIDS.
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