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What Frequency of Monitoring Is Needed for Healthcare in an HIV-infected Person?
Joanne Reekie*1, B Gazzard2, H Sambatakou3, L Machala4, A Chiesi5, J van Lunzen6, N Clumeck7, O Kirk8, A Mocroft1, J Lundgren8, and EuroSIDA study group
1Royal Free and Univ Coll Med Sch, London, UK; 2Chelsea and Westminster Hosp, London, UK; 3Ippokration Gen Hosp, Athens, Greece; 4Faculty Hosp Bulovka, Pargue, Czech Republic; 5Inst Superiore di Sanita, Rome, Italy; 6Univ Med Ctr Hamburg-Eppendorf, Germany; 7Hosp St Pierre, Brussels, Belgium; and 8Copenhagen HIV Prgm, Univ of Copenhagen, Denmark
Background: Current frequency of routine clinic
visits across Europe is 3 to 4 months. The aim of this study was to assess
whether patients on a stable and fully suppressed combination ART (cART)
regimen could be monitored less often.
Methods: EuroSIDA patients were included if they had
not switched cART, had maintained maximal viral suppression, had demonstrable
increase in CD4 count levels (at least 100/mm3 above pre cART
levels), were not severely immunosuppressed (CD4 <200/mm3), and
had no morbidity recorded for a period of more than 12 months; baseline was defined
as the end of this 12 months. The rate of failure was assessed by Kaplan-Meier
and Cox proportional hazards models. Failure was defined as one or more of the
following: deterioration of immune function (CD4 <200 mm3 or CD4
<pre cART level), 2 consecutive HIV RNA levels >500 copies/mL, new
morbidity (AIDS or non-AIDS) or death.
Results: We included2082 patients. Median CD4 and
viral load at starting cART was 220/mm3 and 4.63 copies/mL, and at
baseline was 520/mm3 and 1.70 copies/mL, respectively. Median time
between starting cART and baseline was 2.8 years. There was an estimated 0.3%
(95%CI 0.1 to 0.5) chance of failure within 3 months, increasing to 2.2% (1.6
to 2.8) and 6.2% (5.2 to 7.2) after 6 and 12 months, respectively (see the figure).
The main reason for failure was viral rebound, 4.9% (4.0 to 5.8) after 12 months.
The individual risk of deterioration of immune function, new morbidity (AIDS or
non-AIDS), or death, were all <1% over 12 months. After adjustment,
predictors of failure were time with uncontrolled viremia after starting cART,
prior to baseline (RH = 1.04 per month (95%CI 1.01 to 1.07), and a NNRTI-based
regimen at baseline (0.78, 0.63 to 0.97)). In patients with <6 months uncontrolled
viremia and on a NNRTI-based cART regimen, the probability of failure at 3, 6,
and 12 months was 0.2%, 1.4%, and 4.1%, respectively (see the figure).
Conclusions: Patients who have responded well to
cART and are on a well-tolerated and fully suppressive cART regimen,
particularly if they have experienced periods with complete viral suppression
and if the regimen contains a NNRTI, have a low chance of failure of cART for
the next 3 to 6 months, but increases thereafter. For such patients it appears
reasonable to extend visit intervals to 6 months, with cost and time savings to
both the treating clinics and the patients.
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