Determinants of CD4 count recovery among severely immunosuppressed HIV patients initiated on antiretroviral therapy: a prospective cohort study in KwaZulu-Natal, South Africa

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Background: . This study utilised survival analysis techniques to determine time to CD4 count recovery and to identify determinants among PLWH with severe immunosuppression who were initiated on ART in KwaZulu-Natal, South Africa. Materials and methods: . Participants were followed until recovery; those who did not recover, were lost to follow-up, or died were censored. Kaplan-Meier curves estimated median survival time, while Cox and Weibull regression models identified risk factors associated with CD4 recovery. Results: Among 2,528 participants (median age 32 years), 1,803 had viral load <400 copies/mL, 1,589 were females, and 524 had TB. By the end of the study, 727 achieved CD4 recovery. Kaplan-Meier estimates showed median time to recovery of nearly 40 months for females and 59 months for males. The Weibull model outperformed the Cox model. Male participants had a 41% lower hazard of recovery than females [HR: 0.589, 95% CI: 0.497-0.698], while rural care was associated with a 49% higher hazard of recovery than urban settings [HR: 1.494, 95% CI: 1.228-1.818]. TB-coinfected participants had a 39.5% lower hazard [HR: 0.605, 95% CI: 0.489-0.748], whereas those with viral suppression had a 49% higher hazard of recovery [HR: 1.489, 95% CI: 1.213-1.826]. Conclusion: Delayed CD4 recovery among males, urban residents, TB-coinfected participants, and those with unsuppressed viral load (>400 copies/mL) underscores the need for targeted, differentiated HIV care strategies to accelerate immunological recovery and reduce HIV-related morbidity. Policymakers should prioritise male-focused interventions, strengthened TB-HIV integrated services, intensified adherence and viral load monitoring, and context-specific interventions in urban settings to accelerate immunological recovery and reduce HIV-related morbidity.

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