Abstract
Late Presentation With HIV in Africa: Phenotypes, Risk, and Risk Stratification in the REALITY Trial
Siika, A.
McCabe, L.
Bwakura-Dangarembizi, M.
Kityo, C.
Mallewa, J.
Berkley, J.
Maitland, K.
Griffiths, A.
Baleeta, K.
Mudzingwa, S.
Abach, J.
Nathoo, K.
Thomason, M. J.
Prendergast, A. J.
Walker, A. S.
Gibb, D. M.
Reality Trial Team
Clin Infect Dis. 2018; 66S140-S146
Permanent descriptor
https://doi.org/10.1093/cid/cix1142BACKGROUND: Severely immunocompromised human immunodeficiency virus (HIV)-infected individuals have high mortality shortly after starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. METHODS: The Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children >/=5 years of age with CD4 counts .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 five late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/microL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/microL) 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/microL), but low symptom burden and maintained fat mass. The remaining groups had 4%-6% mortality. CONCLUSIONS: Clinical and laboratory features identified 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. CLINICAL TRIALS REGISTRATION: ISRCTN43622374.
