Immunovirological outcomes and resistance patterns at 4 years of antiretroviral therapy use in HIV-infected patients in Cambodia.

OBJECTIVES: To report immunovirological outcomes and resistance patterns in adults treated with triple combination antiretroviral therapy (cART) for 4 years in an HIV programme of Phnom Penh, Cambodia. METHODS: It is a longitudinal study and cross-sectional evaluation of adults receiving cART for 4 years. CD4 cell counts and HIV-1 RNA were quantified, and resistance patterns were determined. Drug-related toxicity was assessed by clinicians and through laboratory testing. RESULTS: After 4 years of cART start, the cumulative probability of retention in care was 0.80 and survival among patients not lost to follow-up was 0.85. A total of 349 patients (98% of eligible) participated in the cross-sectional evaluation. Ninety per cent were receiving first-line therapy, 29% stavudine- and 58% zidovudine-containing regimens (compared with 94% and 3% at cART initiation). Ninety-three per cent of patients were clinically asymptomatic, and severe lipodystrophy and dyslipidemia were diagnosed in 7.2% and 4.0%, respectively. Good treatment adherence was reported by 83% of patients. Median CD4 T-cell count was 410 cells/µl [IQR 290-511], and 90% of patients had >200 cells/µl. Only 15 (4%) patients had detectable HIV viral load (eight had <200 CD4 cells/µl), five had thymidine analogue mutations, and nine were resistant to two drug classes. In an intention-to-treat analysis, 26.1% (95% CI 22.0-30.5) of patients had failed first-line therapy. CONCLUSIONS: In this Cambodian cohort of adults who started cART at an advanced stage of HIV disease, we observed good clinical and immunovirological outcomes and self-reported treatment adherence at 4 years of therapy.

Cryptococcal meningitis in HIV-infected patients: a longitudinal study in Cambodia.

OBJECTIVE: To describe the frequency of diagnosis of cryptococcosis among HIV-infected patients in Phnom Penh, Cambodia, at programme entry, to investigate associated risk factors, and to determine the incidence of cryptococcal meningitis. METHODS: We analysed individual monitoring data from 11,970 HIV-infected adults enrolled between 1999 and 2008. We used Kaplan-Meier naïve methods to estimate survival and retention in care and multiple logistic regression to investigate associations with individual-level factors. RESULTS: Cryptococcal meningitis was diagnosed in 12.0% of the patients: 1066 at inclusion and 374 during follow-up. Incidence was 20.3 per 1000 person-years and decreased over time. At diagnosis, median age was 33 years, median CD4 cell count was 8 cells/µl, and 2.4% of patients were receiving combined antiretroviral therapy; 38.7% died and 34.6% were lost to follow-up. Of 750 patients alive and in care after 3 months of diagnosis, 85.9% received secondary cryptococcal meningitis prophylaxis and 13.7% relapsed in median 5.7 months [interquartile range 4.1-8.8] after cryptococcal meningitis diagnosis (relapse incidence=5.7 per 100 person-years; 95%CI 4.7-6.9). Cryptococcal meningitis was more common in men at programme entry (adjusted OR=2.24, 95% CI 1.67-3.00) and fell with higher levels of CD4 cell counts (P<0.0001). CONCLUSIONS: Cryptococcal meningitis remains an important cause of morbidity and mortality in Cambodian HIV-infected patients. Our findings highlight the importance of increasing early access to HIV care and cryptococcal meningitis prophylaxis and of improving its diagnosis in resource-limited settings.