Background

Structured treatment interruptions of highly-active antiretroviral therapy (HAART) might be particularly relevant for sub-Saharan Africa, where cost-saving strategies could help to increase the number of patients on HAART. We did a randomised trial of structured treatment interruption in Abidjan, Côte d'Ivoire.
Methods

HIV-infected adults were randomised to receive continuous HAART (CT), CD4-guided HAART (CD4GT) with interruption and reintroduction thresholds at 350 and 250 cells per mm3, respectively, or 2-months-off, 4-months-on HAART. Primary endpoints were death and severe morbidity (any WHO stage 3 or 4 events and any events leading to death) at month 24. We report data from the CT and CD4GT groups until Oct 31, 2005, when the data safety monitoring board recommended to prematurely stop the CD4GT arm. Analyses were intention-to-treat. This study is registered at ClinicalTrials.gov, number NCT00158405.
Results

326 adults (median CD4 count nadir 272 per mm3) were randomised to the CT or CD4GT groups and followed up for median of 20 months. Incidence of mortality (per 100 person-years) was not different between groups (CT 0·6, CD4GT 1·2; p=0·57). Incidence of severe morbidity (per 100 person-years) was higher in the CDG4T group (17·6) than in the CT group (6·7; p=0·001). The most frequent severe events were invasive bacterial diseases. 79% of severe morbidity episodes occurred in patients with CD4 count 200–500 per mm3.
Conclusion

Patients on CD4GT had severe morbidity rates 2·5-fold higher than those on CT. This difference was mainly due to high rates of common diseases in patients with CD4 count 200–500 per mm3. This CD4-guided structured treatment interruption strategy should not be recommended in Abidjan.