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: 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.