Patients with Advanced HIV Type 1 Infection Initiating Antiretroviral Therapy in Botswana: Treatment Response and Mortality

Abstract

The response to highly active antiretroviral treatment (HAART) and predictors of mortality among patients with advanced HIV infection (CD4⁺ cell count <50 cells/mm³) in Botswana are described. Clinical and laboratory data for 349 patients with CD4 <50 cells/mm³ initiating HAART from January 23 to November 18, 2002 at Princess Marina Hospital in Gaborone, Botswana were extracted from clinical charts and electronic patient management systems. The Kaplan–Meier method was used to estimate survival and log-rank tests used for group comparisons. Cox regression was used to identify independent predictors of survival. A total of 349 adults initiated HAART. In all, 78.2% (95% CI: 73.7%, 82.9%) of patients survived 1 year. Among survivors, the mean CD4⁺ cell count increase was 239.8 cells/mm³ (95% CI: 217.0, 262.8) at 12 months; 92.1% (95% CI: 87.8%, 94.9%) of patients (as treated) had plasma HIV-1 RNA ≤400 copies/ml at 9 months declining to 59.9% (95% CI: 54.7%, 64.9%) (ITT). There was a 2-fold higher mortality rate among patients with CD4⁺ ≤10 cells/mm³ compared to 11–49 cells/mm³, hazard ratio (HR) = 1.91 (95% CI:1.16, 3.14). A 10 cell/mm³ higher CD4⁺ cell count corresponded to a 22% decrease in hazard of death (HR = 0.78; 95% CI: 0.64, 0.94). Lower baseline CD4⁺ cell count (p < 0.001) and WHO clinical stage 4 HR = 2.41 (95% CI:1.32, 4.38) were independent predictors of poorer survival. HAART confers significant benefit even among persons with advanced immunosuppression. Adults with CD4⁺ cell counts ≤10 cells/mm³ and/or WHO clinical stage 4 disease at the time of HAART initiation have a higher risk of death.