The Impact of Different CD4 Cell-Count Monitoring and Switching Strategies on Mortality in HIV-Infected African Adults on Antiretroviral Therapy: An Application of Dynamic Marginal Structural Models.
Bottom Line: Assumptions included no direct effect of randomized group on mortality or confounders and no unmeasured confounders which influenced treatment switch and mortality or treatment switch and time-dependent covariates.After 48 weeks of first-line ART, 2,946 individuals contributed 11,351 person-years of follow-up, 625 switches, and 179 deaths.These findings support a benefit from identifying patients immunologically failing first-line ART at 48 weeks.
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Mentions: Under a strategy defined by switching at the first CD4 count <100 or non-Candida WHO 4 event (CD4 <250), we found no survival advantage at 240 weeks for 12-weekly CD4 counts as compared with 24-weekly CD4 counts (−0.2%, 95% CI: −1.4, 0.7) and observed only small, nonsignificant survival advantages for 12-weekly CD4 counts compared with less frequent CD4-monitoring strategies, including a single (baseline) CD4 count 48 weeks after ART initiation (0.9% (95% CI: −1.0, 2.7) at 240 weeks) (Table 3, Figure 2). Compared with no CD4 monitoring, the survival benefit derived from a single CD4 count after 48 weeks of first-line ART was significant (2.4% (95% CI: 1.3, 3.9) at 240 weeks). Under 12-weekly CD4 counts, 2.2% of follow-up would be spent with CD4 count <100 as compared with 2.7% and 3.6% under 24-weekly and 48-weekly CD4 counts, 6.6% with a single CD4 count after 48 weeks of first-line ART, and 9.4% with no CD4 monitoring (Web Figure 2). A single CD4 count after 48 weeks of first-line ART improved survival at 240 weeks by 1.2% (95% CI: 0.2, 2.3) and 1.9% (95% CI: 0.7, 3.5) as compared with a single CD4 count after 72 and 96 weeks of first-line ART, respectively.Figure 2.