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Predicting Long-Term CD4-Cell Counts and Viral Loads

Pretreatment CD4-cell count, age at initiation of therapy, and early treatment response are strong predictors of CD4-cell recovery and virologic suppression 5 to 12 years after ART initiation.


Very few studies have examined CD4-cell counts and viral loads in patients on long-term potent antiretroviral therapy (ART). Here, researchers evaluate data from 614 men in the MACS cohort who had been taking ART consistently for 5 to 12 years.

At the time of ART initiation, 12% of the men were aged 50 and older, 40% were antiretroviral-naive, and more than 50% had CD4 counts 350 cells/mm3 and viral loads 10,000 copies/mL. After 5 to 12 years of ART, the median CD4 count was 585 cells/mm3, and viral loads were undetectable at 78% of study visits. Multivariate analyses revealed the following:

•Pretreatment CD4-cell counts 500 cells/mm3 and age 50 at ART initiation were both associated with lower long-term CD4-cell counts. Among patients who were antiretroviral-naive at ART initiation, older men gained an average of 60 fewer CD4 cells/mm3 than younger men.
•Remaining on the same first or second regimen during the first 5 years of treatment and maintaining virologic suppression for at least half that time were both associated with higher long-term CD4-cell counts.
•Virologic response during the first 5 years of ART and complete adherence to ART both predicted long-term virologic suppression.
•Protease inhibitors and nonnucleoside reverse transcriptase inhibitors were equally likely to suppress viral loads and also had similar effects on CD4-cell recovery.
Comment: Three main points emerge from this study. First, pretreatment CD4-cell counts predict subsequent counts, even many years later. Second, older age at ART initiation reduces the likelihood of a sustained improvement in CD4-cell counts. Finally, adherence and virologic response predict the durability of a regimen, with the best results observed in patients who are treated successfully on their first or second regimens. In aggregate, these data suggest that initiating ART at an earlier stage of HIV infection, with the most potent regimen that an individual can tolerate and commit to, will provide excellent long-term results — especially since all of today's preferred regimens are virtually guaranteed to lead to virologic suppression, provided that adherence is adequate.

— Sonia Nagy Chimienti, MD

Published in Journal Watch HIV/AIDS Clinical Care August 1, 2011

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