Factors associated with timing of initiation of antiretroviral therapy among HIV-1 infected adults in the Niger Delta region of Nigeria

Introduction: Based on growing evidence mainly from countries outside Sub-Saharan Africa, the World Health Organisation (WHO) now recommends initiation of antiretroviral therapy (ART) in HIV-infected individuals in developing countries when CD4 cell count (CD4+) is ≤ 500cells/ul. Nigeria accounts for about 14% of the estimated HIV/AIDS burden in Sub-Saharan Africa. We evaluated the factors associated with timing of initiation of ART among treatment-ineligible HIV-infected adults from Nigeria. Methods: We retrospectively reviewed the hospital records of ART ineligible HIV-infected adults who enrolled into HIV care between January 2008 and December 2012 at two major tertiary hospitals in Bayelsa State, South-South Nigeria. Demographic, clinical and laboratories data were obtained at presentation, at each subsequent visit at 6 monthly intervals and at time of initiation of ART. Cox proportional regression and Kaplan-Meier survival analysis were used to evaluate independent predictors of time to initiation of ART. Results: Amongst the 280 study participants, 70.6% were females, 62.6% had CD4+ ≥500cells/ul, 48.4% had WHO HIV Stage 1 disease and 34.3% were lost to follow up. In a cohort of 180 participants followed up for ≥3months, participants with CD4+ of 351-500cells/ul and stage 2 disease were more likely to start ART earlier than those with CD4+ > 500cells/ul (Hazard ratio [HR]-1.7, 95% confidence interval [CI] of 1.0-2.9) and stage 1 disease (HR-2.3 (95% CI-1.3-4.2) respectively. HIV-infected adults with faster CD4+ decay required earlier ART initiation, especially in the first year of follow up. Conclusion: ART-ineligible HIV-infected adults on follow up in South-South Nigeria are more likely to require earlier initiation of ART if they have stage 2 HIV disease or CD4+ ≤500cells/ul at presentation. Our findings suggest faster progression of HIV-disease in these groups of individuals and corroborate the growing evidence in support for earlier initiation of ART

Distribution of study participants according to outcome and duration of follow up.

<p>Distribution of study participants according to outcome and duration of follow up.</p

Predictors of time to ART initiation as determined by Cox proportional regression analysis.

<p>Predictors of time to ART initiation as determined by Cox proportional regression analysis.</p

Temporal 6monthly median CD4 cell counts according to ART status.

<p>At each individual time points, the observed median CD4 cell counts were significantly higher in participants who were yet to start ART (p<0.0001 at each indivudal time points of 0, 6, 12 and 24 months and p = 0.0001 at 18months; Mann Whitnet test). Among study participants who started ART, the graph shows a steep and progressive drop in median CD4 cell counts in the first year of follow up.</p

Baseline Demographic and clinical variables of study participants in relation to ART status.

<p>Baseline Demographic and clinical variables of study participants in relation to ART status.</p

Kaplan-Meier curves of time to initiation of ART in relation to WHO HIV stage.

<p>The median time to ART initiation was significantly shorter in participants with stage 2 disease (15months) than participants with stage 1 disease (23months).</p

Kaplan-Meier curves of time to initiation of ART in relation to CD4 cell count group.

<p>The median time to ART initiation was significantly shorter in participants with CD4 cell count of 351-500cells/ul than those (16months) with CD4 count >500cells/ul (23months).</p