Individuals starting antiretroviral treatment (ART) with advanced HIV-disease (CD4 count ≤200 cells/µL) may have higher rates of early attrition from care due to HIV-related morbidity and mortality. We evaluated the impact of advanced HIV disease on treatment linkage and retention in a routine clinical setting in Botswana.
The Botswana Combination Prevention Project (BCPP) is a cluster-randomized trial evaluating the impact of a combination prevention package on HIV incidence in 30 rural and semi-urban communities. This sub-analysis of the 15 intervention communities compares rates of linkage to care, ART initiation, retention in care, and virological suppression in patients identified through community testing between November 2013 and May 2016 with CD4 counts ≤200 cells/µL versus those with CD4 counts >200 cells/µL. Patients were eligible for ART if CD4 counts were ≤500 cells/µL or viral load ≥10,000 copies/ml. Data were censored at the end of July 2017.
BCPP assessed HIV status in 44,223 individuals; 10,359 (23%) were HIV-infected, 2,706 (26%) of whom were not on ART and were referred for HIV care. Of the 2,560 who had a point-of-care CD4 test, 519 (20%) had CD4 ≤200 cells/µL. 2041 (80%) had CD4 >200 cells/µL of whom 1578 were elgible for ART. Rates of linkage to care were lower in individuals with CD4 ≤200 cells/µL compared to ART eligible individuals with CD4 >200 cells/µL (78% vs 88% at 6 months, p<0.001 and 93% vs 96% overall, p=0.005), as were rates of ART initiation (84% vs 89%, p=0.003). Mortality was 2.3% (12/519) in those with CD4 ≤200 cells/µL compared 1.1% (18/1578) with CD4 >200 cells/µL, p=0.05. By July 2017, 392 (76%) individuals in the CD4 ≤200 cells/µL were in care and on ART compared to 1301 (82%) with CD4 >200 cells/µL, p=0.001 (Table 1). Among those who initiated ART at least 6 months prior to data censoring, retention in care was 89% (365/408) in the low CD4 group and 93% (1,231/1,331) in the CD4>200 cells/µL group, p=0.05. Rates of viral suppression among those in care were similar in the two groups.
Twenty percent of HIV-infected individuals not on ART had advanced HIV-disease. Those with advanced disease had lower rates of linkage to care, ART initiation, and retention in care, and higher mortality compared to healthier HIV-infected individuals. Once retained in ART care, rates of viral suppression were high. These data highlight the need to focus efforts on earlier identification of HIV-infected persons.