Early immunologic response and subsequent survival among malnourished adults receiving antiretroviral therapy in Urban Zambia

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Abstract
Objective: To evaluate the relationship between early CD4+ lymphocyte recovery on antiretroviral therapy (ART) and subsequent survival among low body mass index (BMI) HIV-1-infected adults. Design: Retrospective analysis of a large programmatic cohort in Lusaka, Zambia. Methods: We evaluated ART-treated adults enrolled in care for more than 6 months. We stratified this study population according to World Health Organization (WHO) malnutrition criteria: normal (BMI ≥18.5 kg/m2), mild (17.00–18.49), moderate (16.00–16.99), and severe (+ cell count change over the first 6 months on ART. To account for effect modification associated with baseline CD4+ cell count, a weighted summary measure was calculated. Results: From May 2004 to February 2009, 56 612 patients initiated ART at Lusaka district clinics; of these, 33 097 (58%) were included in this analysis. The median change in 0–6 month CD4+ cell count in each baseline BMI strata varied from 127 to 131 cells/μl. There was a statistically significant, inverse association between baseline BMI and the post 6-month hazard for mortality only among those patients with less than 100 cells/μl increase in the first 6 months of ART. A CD4+ cell count increase of at least 100 cells/μl over the first 6 months of ART was not associated with a higher hazard for mortality, regardless of baseline BMI. Conclusions: Low baseline BMI and attenuated CD4+ cell count response at 6 months had a compounding, negative impact on post 6-month survival. Specific guidelines for monitoring ART response using immunologic criteria may be warranted for low BMI patients.

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