1. Suboptimal immune response among adults on first-line antiretroviral therapy within the IeDEA East Africa cohort Authors: Nakanjako D, Kiragga A, Yiannoutsos C, Kambugu A, Easterbrook P, on behalf of IeDEA- EA Abstract # TUPDB0105 IAS 30th June-3 July 2013, Kuala Lumpar Malaysia

2. Definitions of suboptimal CD4 recovery i)magnitude criteria: CD4 increase <50 cells at 6 months, <100 cells at 12 months and <200 cells at 24 months ii)CD4 threshold criteria: absolute CD4 count <200 cells/UL at 6, 12 and 24 months iii) Population-specific criteria: Lowest quartile CD4 count increases in the HAART cohort Tuboi SH, JAIDS 2007, Lawn SD, BMC ID, 2007, Lawn SD, AIDS 2001

3. Statistical methods Used Kaplan Meier survival analysis to analyse time to normalization (CD4 > 500 cells) Considered competing risks of death and loss to follow-up

4. Overall 83,926 adults initiated antiretroviral therapy at 7 sites in East Africa 6 months 23029 (27%) In-care with a CD4 measurement 24 months 10232 (12%) In-care with a CD4 measurement CD4 recovery SuboptimalOptimalSuboptimalOptimal 5528 (25%)17501 (75%) 5183 (51%)5049 (49%) OI after suboptimal response 996 (18%)12498 (14%) 612 (12%)463 (9%) P<0.0001P=0.0001

5. Incidence of normalisation with competing risks of death and Loss to follow up Years from ART initiation Cumulative incidence of achieving CD4≥ 350 cells/UL Cumulative incidence of achieving CD4≥500 cells/UL 126.3%15.9% 241.5%22.0% 349.9%27.3% 454.7%33.2% 557.7%37.7% 659.8%40.8% 726.6%34.4% 861.9%45.2% 98.6%36.4% 1063.0%49.8%

6. Policy issues Need to increase access to routine CD4 in routine HIV care & treatment programs Routine viral loads for poor CD4 responders to identify suboptimal responder population Increase adherence and retention in care to allow quality follow up Interventions to optimise immune recovery among suboptimal responders despite viral suppression

7. Acknowledgement