HIV treatment who have a low CD4 cell count are especially likely to achieve an
undetectable viral if they attend their routine clinic appointments, research
published in the online edition of the Journal
of Acquired Immune Deficiency Syndromes suggests.
The US study
showed that retention in HIV care had a stronger association with viral
suppression for people with a low CD4 cell count than people with
stronger immune systems.
with higher CD4 cell counts were more likely to achieve an undetectable viral
load. However, the effect of regular clinic attendance on the chances of viral
suppression was greater for people with immune suppression.
“While it is well
established that retention in care is important for all HIV-infected patients”,
write the authors, “our data suggest that retention in care may be even more
central to achieving optimal virologic outcomes for persons with advanced HIV
population consisted of 35,433 adults living with HIV who received care at 18
centres across the United States between 2006 and 2011. The investigators used
three separate measures to define retention in care:
- Two or more outpatient visits
separated by 90 or more days during a calendar year.
- A gap of less than six months
between follow-up appointments.
- Attending clinic appointments
every three months over the course of a calendar year.
was defined as a viral load below 400 copies/ml.
The patients were
categorised according to their CD4 cell counts: below 200, 201-350, 351-500 and
over 500 cells/mm3.
conducted a series of analyses to see which factors were associated with
retention in care and viral suppression.
The proportion of people taking HIV therapy increased over the study period from 76 to 85% and
median CD4 cell count at the time of entry to care increased from 399 to 476
Analysis of clinic
attendance records showed that between 83 and 85% of patients had two or more
clinic visits separated by at least 90 days in a calendar year; 75 to 78% did not
have a 6-month gap between appointments; and 34 to 39% had clinic visits in all
four calendar quarters.
improvements in HIV treatment and care during the period of the study, the
proportion of people achieving a viral load below 400 copies/ml increased
from 60% in 2006 to 79% in 2011.
retention measure, it was clear that the higher the initial CD4 cell count, the
greater the probability of viral suppression. It was also apparent that at all
CD4 cell counts, people who were retained in care were more likely to achieve
an undetectable viral load than people who did not attend their regular
clinic appointments. It was also notable that the effect of retention in care
on viral suppression was greater at lower compared to higher CD4 cell counts.
explored this final point in greater detail. They found that the association
between retention in care and viral suppression was strongest for people with
a CD4 cell count below 200 cells/mm3 (AOR = 2.33, 95% CI,
2.16-2.51). The association diminished as CD4 cell count increased (201-350 cells/mm3, AOR = 1.96, 95%
CI, 1.81-2.12; CD4 cell count 351-500 cells/mm3, AOR = 1.65, 95% CI,
1.53-1.78; CD4 cell count above 500 cells/mm3, AOR = 1.22, 95% CI,
“Retention in care
is more strongly associated with viral suppression in patients with low CD4
counts,” comment the authors.
They note that
people with low CD4 cell counts have an increased risk of opportunistic
infections, HIV-related complications, are often taking multiple therapies and
may also be living with social problems. “Maintaining a continuous,
high-quality, relationship with a provider may help patients with advanced HIV
disease manage these issues, and may explain why viral suppression is more
strongly associated with retention in care in this population compared to
individuals with higher CD4 cell counts,” suggest the authors.
They conclude: “Our
findings have important implications for improving the health of patients with
advanced HIV disease and emphasize the role of retention in care in test-and-treat approaches to HIV prevention, demonstrating the added value of retaining
people with lower CD4 counts in care.”