Details on IRIS in South Africa

Summary and Comment |
March 31, 2008

Details on IRIS in South Africa

  1. Salim S. Abdool Karim, MD, PhD

In a South African AIDS clinic, about 10% of patients experienced immune reconstitution inflammatory syndrome shortly after initiating ART. Low baseline CD4-cell count was a major predictor of the syndrome.

  1. Salim S. Abdool Karim, MD, PhD

Potent antiretroviral therapy (ART) substantially reduces both the likelihood of opportunistic infections (OIs) and the progression of HIV infection to AIDS. Shortly after starting ART, however, as many as 25% of patients experience clinical worsening because of subclinical opportunistic pathogens or recurrence of previously treated conditions. This phenomenon is commonly known as immune reconstitution inflammatory syndrome (IRIS).

Although the burden of OIs is high in sub-Saharan Africa, relatively little is known about the incidence and outcomes of IRIS in this region. To address this gap, investigators conducted a prospective study among AIDS patients initiating ART in South Africa. Of the 423 enrolled patients, 44 (10.4%) developed IRIS during the first 6 months of ART, corresponding to an incidence rate of 25.1 cases per 100 person-years. The median onset of IRIS was 48 days after ART initiation, with most cases occurring within 90 days. Although clinical manifestations of IRIS were diverse, the most frequently occurring OIs were tuberculosis and dermatologic conditions. Patients who developed IRIS had significantly lower baseline CD4 counts than those without the syndrome (median, 79 vs. 142 cells/mm3), but the two groups had similar viral loads throughout the study. Three of the 44 patients with IRIS died — 2 from IRIS-associated conditions.

Comment

Although IRIS was rarely life threatening in this cohort, one quarter of the patients with the syndrome required hospitalization, which indicates that increased resources may be needed to effectively roll out ART in settings where many patients have low CD4-cell counts when initiating ART. Furthermore, careful monitoring is required to detect IRIS early, particularly among patients with low baseline CD4-cell counts and especially within the first 90 days of treatment.

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