CD4+ cells recovery in HIV positive patients with severe immunosuppression at HAART initiation at Centre Medico-Social Cor-Unum, Kigali

Introduction Up to 30% of HIV infected patients who are receiving HAART do not exhibit a marked increase in the CD4+ T cell count. There is still a concern that immune recovery may not be complete once CD4+ T cells have decreased below 200 cells/μl. The objective is to assess CD4+ cell recovery in HIV+ patients with CD4 count below 200 cells/μl) at HAART initiation. Methods This was a retrospective cohort study among 110 HIV+ patients with initial CD4 count < 200 cells/μl. Baseline Age, sex, CD4 count and viral load were extracted from the patient’s database. After12 months of HAART; CD4 count was done using flow cytometry and viremia by COBAS AmpliPrep/COBAS TaqMan HIV-1 test v 2.0 technology. Results The mean age of the respondents was 35 years; males being 57% and females were 43%. The mean CD4 count before HAART was 110.18 cells/μl whereas at 12 months of HAART; this was 305.01 cells/μl. Though some patients did not achieve a CD4 count of more than 200 cells/μl or a drop in viral load; there was a significant recovery of CD4+ cells (P value=0.000) and viremia following HAART (P value=0.001). Participants aged 18-30 years were likely to have less than 200 cells/μl CD4 count (46.4%) [OR=4.33; 95%CI: 1.29-14.59; P=0.018] than participants aged above 40 years (16.7%). Conclusion HAART was associated with viremia suppression but many patients failed to achieve a CD4 count >200 cells/μl. HAART before severe immunosuppression is a key factor for immune restoration among HIV+ patients.


Introduction
Human immunodeficiency virus (HIV) is a lentivirus; a member of the retrovirus family that causes Acquired Immunodeficiency Syndrome (AIDS) [1]. Human Immunodeficiency Virus Infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) is among the most serious public health challenges man has ever faced; particularly in developing countries with low per capita income [2]. Approximately 35.0 million people were living with HIV worldwide by the end of 2013 [3]. The number of people receiving HIV treatment has tripled in five years and reached 9.7 million in low-and middle-income countries in 2012, and this represents 65% of the global target of 15 million people [4].
Work undertaken by the National Institute of statistics of Rwanda (NISR), in the 2010 RDHS, indicated that in Rwanda, HIV prevalence was 3.7% and 2.2% among women and men, respectively. The city of Kigali, Capital of Rwanda had the highest prevalence (7.3%) in the country [5]. Periodic CD4 count (every three months) and viral load (every 12 months) are used for HIV + patients biological follow up that aims at assessing the infection progression as well as response to HAART [6]. The best limit CD4 count for HAART initiation is 350 cells/μl [7]. Previous studies have showed that factors including age, specific drug regimen, and initial CD4 count influence CD4 count recovery among patients with virological suppression [8][9][10]. A low CD4 count before treatment is a risk factor for not achieving a CD4 count > 200 cells/μl following HAART [11] and studies have documented that the lower the CD4 count at HAART initiation; the longer and more difficult it will be to achieve a net CD4+ recovery [12].

Results
Demographic characteristics of study participants Table 1 presents the age and sex distribution of study participants.
The mean age was 35 years and about half (47.3%) of the respondents were aged between 31-40 years. More males (57%) than females (43%) participated to the study.

CD4+ cells count at HAART initiation and at 12 months of treatment
As shown in

Viral load level among study participants
Viral load median was computed at both time points as shown in Table 4. Median viral load was 23400 HIV RNA copies/ml before HAART. When viral load was expressed in logs for a normal distribution, viral load median was equivalent to 4.3 logs before HAART initiation. After 12 months of HAART; the median viral load dropped to 20 HIV RNA copies/ml (equivalent to 1.3 logs) and the difference in viral load was significant between the two time points (P value = 0.000).

Viral load based on sex and age
Before HAART initiation males had a mean rank viral load 59.9 compared to 49.5 among females but this was not significant (P value= 0.090). Following HAART mean rank of drop in viral load achieved by males was 55.3 and by females 55.8 (P value= 0.766).
Similarly, there was no significant difference between the age and mean rank of viral load before HAART initiation (P value= 0.918) as well as age and mean rank of viral load after 12 months of HAART initiation (P value= 0.063) (  (Table 6). Younger participants were likely to have lower CD4 count but this was not associated with in increase in viremia and could be attributed to prognostic prediction discrepancies between viral load and CD4 count [6].

Conclusion
We conclude that immune recovery is slow among HIV+ patients who start HAART with severe immunosuppression. Early HAART intervention is necessary for achieving effective CD4+ T cell responses and optimal immunological function in HIV+ patients.  Table 1: Demographic attributes of study participants