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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.

Ford D, Robins JM, Petersen ML, Gibb DM, Gilks CF, Mugyenyi P, Grosskurth H, Hakim J, Katabira E, Babiker AG, Walker AS, DART Trial Te - Am. J. Epidemiol. (2015)

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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Survival among human immunodeficiency virus–positive patients on antiretroviral therapy (ART), by randomized trial group (laboratory and clinical monitoring (LCM) or clinically driven monitoring (CDM)) and CD4 cell count at 48 consecutive weeks on first-line ART (baseline), Development of Antiretroviral Therapy in Africa (DART) Trial, Uganda and Zimbabwe, 2003–2008.
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KWV083F3: Survival among human immunodeficiency virus–positive patients on antiretroviral therapy (ART), by randomized trial group (laboratory and clinical monitoring (LCM) or clinically driven monitoring (CDM)) and CD4 cell count at 48 consecutive weeks on first-line ART (baseline), Development of Antiretroviral Therapy in Africa (DART) Trial, Uganda and Zimbabwe, 2003–2008.

Mentions: Given the substantial benefits of a single CD4 count suggested by the dynamic marginal structural model, we compared DART randomized groups by CD4 count at 48 consecutive weeks of first-line ART (Figure 3). Fifty-four (30%) of the 179 subsequent deaths occurred among the 11% of participants with CD4 counts less than 100 cells/mm3 at 48 weeks—16 in the LCM group versus 38 in the CDM group (hazard ratio = 2.39, 95% CI: 1.32, 4.32). In contrast, there were 59 LCM deaths versus 66 CDM deaths among participants with CD4 cell counts greater than or equal to 100 cells/mm3 at 48 weeks (hazard ratio = 1.13, 95% CI: 0.77, 1.65; interaction P for heterogeneity = 0.04). Excluding the 320 participants with CD4 counts less than 100 at 48 weeks, only 525 of 2,626 (20%) participants had a CD4 count less than 100 without a prior WHO 4 event during the subsequent 4 years of follow-up; the observed benefit of CD4 monitoring is small at the population level because such persons are in the minority.Figure 3.


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.

Ford D, Robins JM, Petersen ML, Gibb DM, Gilks CF, Mugyenyi P, Grosskurth H, Hakim J, Katabira E, Babiker AG, Walker AS, DART Trial Te - Am. J. Epidemiol. (2015)

Survival among human immunodeficiency virus–positive patients on antiretroviral therapy (ART), by randomized trial group (laboratory and clinical monitoring (LCM) or clinically driven monitoring (CDM)) and CD4 cell count at 48 consecutive weeks on first-line ART (baseline), Development of Antiretroviral Therapy in Africa (DART) Trial, Uganda and Zimbabwe, 2003–2008.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4581589&req=5

KWV083F3: Survival among human immunodeficiency virus–positive patients on antiretroviral therapy (ART), by randomized trial group (laboratory and clinical monitoring (LCM) or clinically driven monitoring (CDM)) and CD4 cell count at 48 consecutive weeks on first-line ART (baseline), Development of Antiretroviral Therapy in Africa (DART) Trial, Uganda and Zimbabwe, 2003–2008.
Mentions: Given the substantial benefits of a single CD4 count suggested by the dynamic marginal structural model, we compared DART randomized groups by CD4 count at 48 consecutive weeks of first-line ART (Figure 3). Fifty-four (30%) of the 179 subsequent deaths occurred among the 11% of participants with CD4 counts less than 100 cells/mm3 at 48 weeks—16 in the LCM group versus 38 in the CDM group (hazard ratio = 2.39, 95% CI: 1.32, 4.32). In contrast, there were 59 LCM deaths versus 66 CDM deaths among participants with CD4 cell counts greater than or equal to 100 cells/mm3 at 48 weeks (hazard ratio = 1.13, 95% CI: 0.77, 1.65; interaction P for heterogeneity = 0.04). Excluding the 320 participants with CD4 counts less than 100 at 48 weeks, only 525 of 2,626 (20%) participants had a CD4 count less than 100 without a prior WHO 4 event during the subsequent 4 years of follow-up; the observed benefit of CD4 monitoring is small at the population level because such persons are in the minority.Figure 3.

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.

View Article: PubMed Central - PubMed

Show MeSH
Related in: MedlinePlus