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  • br Discussion Our findings indicated

    2022-05-13


    Discussion Our findings indicated that starting ART for asymptomatic HIV-infected pregnant women before their CD4 count falls below 500cells/mm3 is beneficial for CD4 normalization (CD4 recovery to 750cells/mm3 or more) in resource-limited settings. Women who started ART at lower baseline CD4 count (<500cells/mm3) could not catch up with those who had higher baseline CD4 count (≥500cells/mm3) after twelve months of treatment although the rate of CD4 gain was faster among women initiating ART at lower baseline CD4 count. It is well known that having a CD4 count within the normal range among HIV infected individuals is associated with lower risk of HIV-related illnesses (Le et al., 2013, Baker et al., 2008) and a greater life expectancy (May et al., 2014). Although the benefit of early Sulforaphane receptor of ART has been demonstrated by clinical trials (Group TAS, 2015, Group ISS, 2015), the benefit was not uniform across various patient groups. In addition, it is not certain that the observed effectiveness in clinical trials can be replicated in different real program settings in low income settings. Moreover, the types of ART regimens used in clinical trials were not common in low income settings which make generalization of the findings to these settings problematic. Therefore, observational studies demonstrating the benefit of early ART in real clinical settings are necessary. Our study showed that early initiation of ART may be beneficial in preserving or recovering immunity in resource limited settings. The finding ease the concerns that early ART may not be effective for asymptomatic adults with high level CD4 count and supports the recent recommendations of early initiation of ART for all HIV-infected individuals by the WHO (WHO, 2016). Previous studies also reported that initiating ART when the CD4 count is ≥500cells/mm3 compared to deferring treatment until the CD4 drops below 500cells/mm3 significantly increases the likelihood of CD4 normalization (Gras et al., 2007, García et al., 2004, Okulicz et al., 2015). The benefit of early initiation of treatment is further reinforced by previous findings which showed that early initiation of ART preserves immune function (Le et al., 2013). On average CD4 count increased across all baselines CD4 categories during follow-up. However, the rate of CD4 count increase during follow-up was higher among women who initiated ART at a lower baseline CD4 count. The finding is not unexpected as most women who initiated treatment at higher baseline CD4 count already have normal or near normal CD4 count, and are therefore not expected to have large CD4 gains during follow-up. The likely CD4 count trajectory without treatment is a progressive decline after a transient increase during the acute HIV infection phase (Le et al., 2013). Preventing CD4 count decline is the likely benefit of treatment among women who have high baseline CD4 count. Previous studies reported inconsistent findings. Some studies reported a larger CD4 increase among patients with lower baseline CD4 count (Lifson et al., 2011, Sempa et al., 2013), and others demonstrated a similar rate of CD4 increase despite the difference in baseline CD4 count (Lawn et al., 2006, Lewden et al., 2007). Our study could not determine the long term change in CD4 count, as the follow-up time was only twelve months. Findings from a few previous studies evaluating CD4 trajectories over time demonstrated that the CD4 counts continued to increase up to 3 to 4 years after initiation of ART before reaching a plateau after 4–5 years in all CD4 categories (García et al., 2004, Lifson et al., 2011). Other studies indicated that the CD4 counts continue to increase for 7 years among those who initiated treatment at CD4 count less than 350cells/mm3 (Gras et al., 2007, Sempa et al., 2013). However, these studies did not evaluate the effect of treatment initiation at different CD4 levels among asymptomatic HIV-infected individuals. We also evaluated clinical outcomes according to baseline CD4 count. Outcomes such as AIDS defining illnesses and mortality during follow up period were very rare due to the short follow-up time. As a result, we considered WHO stage II–IV HIV-related clinical events in combination. The study demonstrated some evidence of lower risk of HIV-related clinical events among women who initiated ART at baseline CD4 count of ≥500cells/mm3 as compared to women who initiated treatment with a CD4 count below 500cells/mm3, although the confidence intervals were wide due to the small number of events.