Progressive phasing out of baseline CD4+ cell count testing for people living with HIV in Kinshasa, Democratic Republic of the Congo

Abstract

Since 2013, evidence favored earlier initiation of ART because of reduced mortality, morbidity and HIV transmission outcomes [1–3]. In 2015, WHO guidelines recommended that ART should be initiated in everyone living with HIV at any CD4+ cell count [4]. The 2017 consolidated guidelines stated that ART initiation should be offered on the same day to people who are ready to start [5]. Nevertheless, CD4+ cell count testing at baseline remains critical for several reasons at the individual and community levels, in particular to tailor the management of people living with HIV (PLWHIV) having an advanced HIV disease (AHD) defined as CD4+ cell count less than 200 cells/μl or WHO stage 3 or 4 event [5]. Specific interventions for people with AHD include the use of co-trimoxazole prophylaxis, specific tuberculosis diagnosis and preventive treatment, cryptococcal antigen (Ag) screening and preemptive antifungal treatment [5]. People with AHD necessitate close monitoring after ART initiation to detect possible immune reconstitution inflammatory syndrome (IRIS). From a community perspective, CD4+ cell count assessment at presentation for care helps to monitor the level of late presentation for care and to analyze the impact of screening and/or information campaign on this parameter [6]. CD4+ count testing thus remains recommended at baseline in WHO and Democratic Republic of Congo (DRC) guidelines, although the latter do not include CD4+ cell count as an essential baseline parameter and specify that it could be realized depending on the clinical context [7]. However, recommendations to start ART irrespective of CD4+ cell count may lead to declines in baseline CD4+ count assessment [8]. To analyze the modifications in baseline CD4+ testing overtime with a particular focus on recent years following the implementation of the ‘test and treat’ strategy, we performed a retrospective cohort study taking place in Kinshasa, capital of the DRC. The studied population included HIV-positive adults (≥16 years old) newly enrolled in HIV care and initiating ART between January 2006 and June 2020 at 25 HIV urban care facilities. Patient information routinely collected at enrollment in HIV care and during each clinic visit included age, sex and WHO stage. We define CD4+ count testing at baseline as having a CD4+ cell count performed up to 3 months following HIV diagnosis. Approval was obtained from the Ethical Committee of the School of Public Health, University of Kinshasa. Ten thousand one hundred and thirty-seven patients were included in the analysis. 68.3% were women. Median age was 40 years. From 2006 to June, 2020, 2764 (27.3%) had CD4+ count testing at baseline. One thousand one hundred and twenty-two (40.6%) had a CD4+ cell count below 200 cells/μl and 1974 (71.4%) below 350 cells/μl. The percentage of CD4+ cell count testing at baseline dramatically dropped from 2015 to 2020 to reach 0% (Fig. 1a). Among those with no CD4+ cell count at baseline, only 1.5% had a CD4+ count testing later during the follow-up. The probability of having a CD4+ cell count testing thus drastically decreased after 2017.Fig. 1: (a) Trends in baseline CD4+ cell count assessment in people living with HIV during 2006–2020. (b) Percentage of people living with HIV (WHO stage 1 or 2) with CD4+ count above or below 200 cells/μl.PLWHIV with baseline CD4+ assessment were more likely to have WHO clinical stage 3 or 4 disease compared with those without. Importantly, we observed that almost one-third of PLWHIV in WHO clinical stage 1 and 2 had CD4+ cell count below 200 cells/μl (Fig. 1b). We thus observed a major drop in CD4+ cell count testing at baseline. Recently, Nasuuna et al. similarly observed a dramatic decline in baseline CD4+ assessment in Uganda [8]. We showed that CD4+ cell count at baseline have been totally abandoned during the recent years in Kinshasa. One would argue that the clinical evaluation could discriminate PLWHIV at an early stage or at an advanced stage of the disease. However, our analysis confirmed the poor correlation between the WHO clinical stages and the CD4+ cell count [8–10]. Thanks to a better identification of people with severe immunosuppression who are eligible for specific intensified care, CD4+ count assessment is still a critical part of baseline evaluation following HIV diagnosis. If coupled with tailored diagnostic, prophylactic and therapeutic interventions, baseline CD4+ cell count testing could contribute to reduce AIDS-related morbidity and mortality. Factors associated with the observed phasing out in baseline CD4+ count testing should be studied and carefully analyzed to provide solutions to bring down these barriers. Acknowledgements We thank all patients and staff at the HIV care and facilities included in these analyses. Conflicts of interest G.D. is postdoctorate clinical master specialist for the FNRS (Belgium).