Late Presentation with HIV in Africa

Phenotypes, Risk, and Risk Stratification in the REALITY Trial

REALITY Trial Team

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background. Severely immunocompromised human immunodefciency virus (HIV)-infected individuals have high mortality shortly afer starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods. Te Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children =5 years of age with CD4 counts <100 cells/μL initiating ART in Uganda, Zimbabwe, Malawi, and Kenya. Baseline predictors of mortality through 48 weeks were identifed using Cox regression with backwards elimination (exit P >.1). Results. Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P <.04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P =.02). Of fve late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/μL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/μL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/μL), but low symptom burden and maintained fat mass. Te remaining groups had 4%-6% mortality. Conclusions. Clinical and laboratory features identifed groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up.

Original languageEnglish (US)
Pages (from-to)S140-S146
JournalClinical Infectious Diseases
Volume66
DOIs
StatePublished - Mar 4 2018

Fingerprint

Viruses
Phenotype
Mortality
CD4 Lymphocyte Count
Weight Loss
Albumins
Hemoglobins
Hand Strength
Therapeutics
Self Care
Platelet Count
Vomiting
Neutrophils
Fever
Fats
Inflammation
Infection

Keywords

  • Africa
  • HIV
  • immunosuppression
  • mortality

ASJC Scopus subject areas

  • Microbiology (medical)
  • Infectious Diseases

Cite this

Late Presentation with HIV in Africa : Phenotypes, Risk, and Risk Stratification in the REALITY Trial. / REALITY Trial Team.

In: Clinical Infectious Diseases, Vol. 66, 04.03.2018, p. S140-S146.

Research output: Contribution to journalArticle

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title = "Late Presentation with HIV in Africa: Phenotypes, Risk, and Risk Stratification in the REALITY Trial",
abstract = "Background. Severely immunocompromised human immunodefciency virus (HIV)-infected individuals have high mortality shortly afer starting antiretroviral therapy (ART). We investigated predictors of early mortality and {"}late presenter{"} phenotypes. Methods. Te Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children =5 years of age with CD4 counts <100 cells/μL initiating ART in Uganda, Zimbabwe, Malawi, and Kenya. Baseline predictors of mortality through 48 weeks were identifed using Cox regression with backwards elimination (exit P >.1). Results. Among 1711 included participants, 203 (12{\%}) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P <.04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P =.02). Of fve late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25{\%}; median CD4 count, 28 cells/μL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11{\%} mortality; 43 cells/μL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10{\%} mortality) had low CD4 counts (27 cells/μL), but low symptom burden and maintained fat mass. Te remaining groups had 4{\%}-6{\%} mortality. Conclusions. Clinical and laboratory features identifed groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up.",
keywords = "Africa, HIV, immunosuppression, mortality",
author = "{REALITY Trial Team} and Abraham Siika and Leanne McCabe and Mutsa Bwakura-Dangarembizi and Cissy Kityo and Jane Mallewa and Jay Berkley and Kath Maitland and Anna Griffiths and Keith Baleeta and Shepherd Mudzingwa and James Abach and Kusum Nathoo and Thomason, {Margaret J.} and Prendergast, {Andrew J.} and Walker, {Ann Sarah} and Gibb, {Diana M.} and P. Mugyenyi and C. Kityo and V. Musiime and P. Wavamunno and E. Nambi and P. Ocitti and M. Ndigendawani and M. Kemigisa and J. Acen and D. Olebo and G. Mpamize and A. Amone and D. Okweny and A. Mbonye and F. Nambaziira and A. Rweyora and M. Kangah and V. Kabaswahili and J. Abach and G. Abongomera and J. Omongin and I. Aciro and A. Philliam and B. Arach and E. Ocung and G. Amone and P. Miles and C. Adong and C. Tumsuiime and P. Kidega and B. Otto and F. Apio and K. Baleeta and Kara Wools-Kaloustian",
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T1 - Late Presentation with HIV in Africa

T2 - Phenotypes, Risk, and Risk Stratification in the REALITY Trial

AU - REALITY Trial Team

AU - Siika, Abraham

AU - McCabe, Leanne

AU - Bwakura-Dangarembizi, Mutsa

AU - Kityo, Cissy

AU - Mallewa, Jane

AU - Berkley, Jay

AU - Maitland, Kath

AU - Griffiths, Anna

AU - Baleeta, Keith

AU - Mudzingwa, Shepherd

AU - Abach, James

AU - Nathoo, Kusum

AU - Thomason, Margaret J.

AU - Prendergast, Andrew J.

AU - Walker, Ann Sarah

AU - Gibb, Diana M.

AU - Mugyenyi, P.

AU - Kityo, C.

AU - Musiime, V.

AU - Wavamunno, P.

AU - Nambi, E.

AU - Ocitti, P.

AU - Ndigendawani, M.

AU - Kemigisa, M.

AU - Acen, J.

AU - Olebo, D.

AU - Mpamize, G.

AU - Amone, A.

AU - Okweny, D.

AU - Mbonye, A.

AU - Nambaziira, F.

AU - Rweyora, A.

AU - Kangah, M.

AU - Kabaswahili, V.

AU - Abach, J.

AU - Abongomera, G.

AU - Omongin, J.

AU - Aciro, I.

AU - Philliam, A.

AU - Arach, B.

AU - Ocung, E.

AU - Amone, G.

AU - Miles, P.

AU - Adong, C.

AU - Tumsuiime, C.

AU - Kidega, P.

AU - Otto, B.

AU - Apio, F.

AU - Baleeta, K.

AU - Wools-Kaloustian, Kara

PY - 2018/3/4

Y1 - 2018/3/4

N2 - Background. Severely immunocompromised human immunodefciency virus (HIV)-infected individuals have high mortality shortly afer starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods. Te Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children =5 years of age with CD4 counts <100 cells/μL initiating ART in Uganda, Zimbabwe, Malawi, and Kenya. Baseline predictors of mortality through 48 weeks were identifed using Cox regression with backwards elimination (exit P >.1). Results. Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P <.04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P =.02). Of fve late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/μL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/μL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/μL), but low symptom burden and maintained fat mass. Te remaining groups had 4%-6% mortality. Conclusions. Clinical and laboratory features identifed groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up.

AB - Background. Severely immunocompromised human immunodefciency virus (HIV)-infected individuals have high mortality shortly afer starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods. Te Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children =5 years of age with CD4 counts <100 cells/μL initiating ART in Uganda, Zimbabwe, Malawi, and Kenya. Baseline predictors of mortality through 48 weeks were identifed using Cox regression with backwards elimination (exit P >.1). Results. Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P <.04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P =.02). Of fve late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/μL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/μL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/μL), but low symptom burden and maintained fat mass. Te remaining groups had 4%-6% mortality. Conclusions. Clinical and laboratory features identifed groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up.

KW - Africa

KW - HIV

KW - immunosuppression

KW - mortality

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U2 - 10.1093/cid/cix1142

DO - 10.1093/cid/cix1142

M3 - Article

VL - 66

SP - S140-S146

JO - Clinical Infectious Diseases

JF - Clinical Infectious Diseases

SN - 1058-4838

ER -