Initiation of antiretroviral therapy at high CD4+ cell counts is associated with positive treatment outcomes

Abstract

Objective There is limited research investigating the possible mechanisms of how starting combination antiretroviral therapy (cART) at a higher CD4+ cell count decreases mortality. This study investigated the association between initiating cART with short-term and long-term achievement of viral suppression; emergence of any drug resistance and of an AIDS-defining illness (ADI); long-term treatment adherence; and all-cause mortality. Methods This retrospective cohort study included 4120 naive patients who initiated cART between 2000 and 2012. Patients were followed until 2013, death or until the last contact date (varied by outcome). The main exposure was the interaction between period of cART initiation (2000–2006 and 2007–2012) and CD4+ cell count at cART initiation (<500 versus ≥500 cells/μl). We considered both baseline and longitudinal covariates. We fitted different multivariable models using cross-sectional and longitudinal statistical methods, depending on the outcome. Results Patients who initiated cART with a CD4+ cell count at least 500cells/μl in 2007–2012 had an increased likelihood of achieving viral suppression at 9 months and of maintaining an adherence level of at least 95% overtime, and the lowest probability of developing any resistance and an ADI during follow-up. These patients were not the ones with the highest likelihood of maintaining viral suppression over time, most likely due to viral load blips experienced during the follow-up. Conclusion The outcomes in this study likely play an important role in explaining the positive impact of early cART initiation on mortality. These results should alleviate some of the concerns clinicians may have when initiating cART in patients with high CD4+s as recommended by current treatment guidelines.

Baseline CD4 Count and Adherence to Antiretroviral Therapy: A Systematic Review and Meta-Analysis

“…Eighteen studies provided data on 62,823 participants that could be included in the meta-analysis, 20, 21,23,24,[27][28][29][30][31][32]35,36,40,42,44,45,48,49 among which 11 provided adjusted estimates (Fig. 2).…”

Universal test and treat is not associated with sub‐optimal antiretroviral therapy adherence in rural South Africa: the ANRS 12249 TasP trial

“…This could have contributed to the poorer adherence seen in men than women in our study. The majority of studies have reported no sex difference with respect to adherence [23][24][25][26][27][28], with one meta-analysis reporting a marginal association of male sex with higher adherence [17].…”

Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial

“…This could have contributed to the poorer adherence seen in men than women in our study. The majority of studies have reported no sex difference with respect to adherence [22][23][24][25][26][27], with one metaanalysis reporting a marginal association of male sex with higher adherence [16].…”