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In a randomized comparison of nevirapine or abacavir with zidovudine plus lamivudine, routine viral load monitoring was not performed, yet 27% of individuals with viral failure at week 48 experienced resuppression by week 96 without switching. This supports World Health Organization recommendations that suspected viral failure should trigger adherence counseling and repeat measurement before a treatment switch is considered.

We examined whether the timing of initiation of antiretroviral therapy (ART) in routine clinical practice reflected treatment guidelines, which have evolved towards recommending starting therapy at lower CD4 cell counts. MethodsWe analysed longitudinal data on 10 820 patients enrolled in the UK Collaborative HIV Cohort (UK CHIC) Study, which includes seven large clinical centres in south-east England. CD4 cell and viral load measurements performed in the period between 1 January 1997 and 31 December 2003 were classified according to whether ART was subsequently initiated or deferred, to estimate the probability of ART initiation by CD4 count and viral load over time. The effect of nonclinical factors (age, sex, ethnicity, and exposure category) was analysed by logistic regression. Kaplan-Meier analysis was used to estimate the proportion of patients who had initiated ART by a particular CD4 count among 'early' presenters (initial CD4 cell count 4500 cells/mL). ResultsThere was a tendency to initiate ART at lower CD4 cell counts over time in the years 1997-2000, especially in the range 200-500 cells/mL, with little change thereafter. An estimated 34% of HIV-infected individuals having presented early initiated ART at a CD4 count o200 cells/mL. We also found an independent influence of viral load, which was particularly pronounced for CD4 o350 cells/mL. Use of injection drugs was the only nonclinical factor associated with initiation of ART at lower CD4 cell counts. ConclusionsThe initiation of ART in the clinics included in this analysis reflected evolving treatment guidelines. However, an unexpectedly high proportion of patients started ART at lower CD4 counts than recommended, which is only partly explained by late presentation. IntroductionSince the introduction of highly active antiretroviral therapy (HAART) in 1996, successive treatment guidelines from the British HIV Association (BHIVA) have changed towards recommending starting therapy at lower CD4 cell counts [1][2][3][4]. Two recent audits of patients' clinical notes assessed adherence to these guidelines and reported that most patients who started antiretroviral therapy (ART) did so at CD4 cell counts lower than the recommendations of the guidelines [5,6]. In most cases, the authors believe that this reflected late presentation of patients for care at clinical centres. However, analyses were restricted to the [7]. The study provided us with an opportunity to examine whether the trends in CD4 cell count at ART initiation in routine clinical practice reflected changes in BHIVA treatment guidelines. The CD4 cell count range of 200-500 cells/ mL, for which guidelines on when to start ART have changed, was our major focus of interest. We also examined the effect of nonclinical factors, as a number of studies had reported that starting ART depended not only on immunological and virological parameters, but also on patient characteristics, with female sex, younger age, black ethnicity, and injecting drug use (IDU) being associated with being less likely to be...

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