To determine the prevalence of adequate monitoring and the
costs of measuring CD4+ T-lymphocytes (CD4+ cell) and human immunodeficiency
virus (HIV) viral load in people receiving antiretroviral therapy (ART) in
seven countries in the WHO Region of the Americas. Methods We obtained
retrospective, longitudinal data for 14 476 adults who started a first ART
regimen at seven HIV clinics in Argentina, Brazil, Chile, Haiti, Honduras,
Mexico and Peru between 2000 and 2011. We estimated the proportion of 180-day
periods with adequate monitoring, which we defined as at least one CD4+ cell
count and one viral load measurement. Factors associated with adequate
monitoring were analysed using regression methods. The costs of the tests were
estimated.
The median follow-up time was 50.4 months; the proportion of
180-day periods with adequate CD4+ cell counts was 69% while the proportion
with adequate monitoring was 62%. Adequate monitoring was more likely in
participants who were older, who started ART more recently, whose first regimen
included a non-nucleoside reverse transcriptase inhibitor or who had a CD4+
cell count less than 200 cells/µl at ART initiation. The cost of one CD4+ cell
count ranged from 7.37 United States dollars (US$) in Argentina to US$ 64.09 in
Chile; the cost of one viral load measurement ranged from US$ 20.34 in Brazil
to US$ 186.28 in Haiti.
In HIV-infected participants receiving ART in the WHO Region
of the Americas, CD4+ cell count and viral load monitoring was often carried
out less frequently than regional guidelines recommend. The laboratory costs of
monitoring varied greatly.
Table 1 Antiretroviral treatment programmes in seven countries in the WHO Region of the Americas, 2000-2011
| Characteristic | Site of adult HIV clinica | ||||||
|---|---|---|---|---|---|---|---|
| Argentina | Brazil | Chile | Haiti | Honduras | Mexico | Peru | |
| No. of participants in study | 1285 | 2446 | 1080 | 5696 | 789 | 772 | 2408 |
| Start of universal access to ART, year | 2000 | 1991b | 2003 | 2003 | 2003 | 2002 | 2004 |
| Type of clinic | Private | Public | Public | NGO | Public | Public | Public |
| Guidelines used for monitoring ART efficacy | SADI, MOH | MOH | MOH | MOH, PAHO | MOH | MOH | MOH |
| Recommended periodicity of CD4+ cell count monitoring | 3-4 months | 3-6 months | 3-4 monthsc | 6 months | 6 months | 4-6 months | 6 months |
| Cost of one CD4+ cell count, US$d | 7.37 | 17.62 | 64.09 | 32.6 | 14.31 33.39 | 59.67 | 38.12e |
| Source of funding for CD4+ cell count monitoring | Refund from Argentine government, social insurance | Brazilian government | Chilean government | PEPFAR, GFATM | Honduran government, social insurance | Mexican government | Peruvian government |
| Cost of one HIV viral load measurement, US$d | 55.26 | 20.34 | 119.14 | 186.28f | 33.39g160.19h | 119.27 | 86.32 |
| Source of funding for HIV viral load monitoring | Refund from Argentine government, social insurance | Brazilian government | Chilean government | Researchfunded | Honduran government, social insurance | Mexican government | Peruvian government |
Table 2 Characteristics of participants receiving ART in seven countries in the WHO Region of the Americas, 2000-2011
| Participants' characteristic | Site of adult HIV clinica | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Argentina | Brazil | Chile | Haiti | Honduras Mexico | Peru | Total (n = 14 476) | |||
| (n= 2446) (n=1080) (n=5696) | (n = 789) (n = 772) | (n = 2408) | |||||||
| Age in years, median (IQR) | (33-46) | 38 38 39 | (32-45) | (32-46) | 36 34 (30-43) (29-42) | (29-43) | 35 | 37 | |
| (31-45) | |||||||||
| Male sex, no. (%) | 925 (72) | 1611 (66) | 952 (88) | 2480 (44) 422 (53) 673 (87) | 1691 (70) | 8754 (60) | |||
| Probable cause of infection, no. (%) Heterosexual sex | 340 (26) | 1136 (46) | 285 (26) | 0 (0) 471 (60) 219 (28) | 1562 (65) | 4013 (28) | |||
| Homosexual sex | 181 (14) | 833 (34) | 785 (73) | 0 (0) 49 (6) 514 (67) | 831 (35) | 3193 (22) | |||
| Other | 55 (4) | 81 (3) | 9 (1) | 0 (0) 3 (0) 17 (2) | 13 (1) | 178 (1) | |||
| Unknown | 709 (55) | 396 (16) | 1 (0) | 5696 (100) 266 (34) 22 (3) | 2 (0) | 7092 (49) | |||
| CD4+ cell count at ART initiation, no. (%) Data missing | 306 (24) | 426 (17) | 302 (28) | 772 (14) 151 (19) 132 (17) | 326 (14) | 2415 (17) | |||
| 200-350 cells/µL < 200 cells/µL | 306 (24) | 771 (32) | 373 (35) | 3035 (53) 447 (57) 355 (45) | 1222 (51) | 6509 (45) | |||
| 200-350 cells/µL | 349 (27) | 650 (27) | 234 (22) | 1537 (27) 146 (19) 184 (24) | 526 (22) | 3626 (25) | |||
| 350 cells/µL | 324 (25) | 599 (24) | 171 (16) | 352 (6) 45 (6) 101 (13) | 334 (14) | 1926 (13) | |||
| Prior AIDS-defining eventb at ART initiation, no. (%) | 54 (4) | 172 (7) | 292 (27) | 1223 (21) 252 (32) 332 (43) | 848 (35) | 3173 (22) | |||
| Prior AIDS-defining event or CD4+ cell count < 200 cells/µL at ART initiation | 335 (26) | 871 (36) | 541 (50) | 3423 (60) 536 (68) 486 (63) | 1515 (63) | 7707 (53) | |||
| NNRTI-based ART regimen, no. (%) | 869 (68) | 1270 (52) | 858 (79) | 5279 (93) 745 (94) 607 (79) | 2024 (84) | 11 652 (80) | |||
Full article at:
By:
Pablo F Belaunzarán-Zamudioa, Yanink N Caro-Vegaa, Bryan E Shepherdb, Brenda E Crabtree-Ramíreza, Paula M Luzc, Beatriz Grinsztejnc, Carina Cesard, Pedro Cahnd, Claudia Cortése, Marcelo Wolffe, Jean W Papef, Denis Padgettg, Eduardo Gotuzzoh, Catherine McGowani, Juan G Sierra-Maderoa
a Clínica de Inmuno-Infectología, Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Calle Vasco de Quiroga 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, México Distrito Federal, CP 14080, Mexico.
b Department of Biostatistics, Vanderbilt University, Nashville, United States of America (USA).
c Instituto de Pesquisa Clínica Evandro Chagas, Fundacão Oswaldo Cruz, Rio de Janeiro, Brazil.
d Fundación Huésped, Buenos Aires, Argentina.
e Fundación Arriarán, Universidad de Chile, Santiago, Chile.
f Le Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, Port-au-Prince, Haiti.
g Instituto Hondureño de Seguridad Social and Hospital Escuela, Tegucigalpa, Honduras.
h Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru.
iDepartment of Medicine, Vanderbilt University, Nashville, USA.
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