CD4+ cell count 6 years after commencement of highly active antiretroviral therapy in persons with sustained virologic suppression

Abstract

Background. Sustained suppression of the human immunodeficiency virus (HIV) type 1 RNA load with the use of highly active antiretroviral therapy (HAART) results in immunologie improvement, but it is not clear whether the CD4 + cell count increases to normal levels or whether it reaches a less-than-normal plateau. We characterized the increase in the CD4+ cell count in patients in clinical practice who maintained sustained viral suppression for up to 6 years. Methods. All patients were from the Johns Hopkins HIV Clinical Cohort, a longitudinal observational study of patients receiving primary HIV care in Baltimore, Maryland, who were observed for >1 year while receiving HAART and who had sustained suppression of the HIV RNA load at <400 copies/mL. We analyzed annual change in the CD4+ cell count for up to 6 years after the start of HAART, stratified by baseline CD4+ cell counts of ≤200, 201-350, >350 cells/μL, and we assessed the development of clinical events (death and new acquired immunodeficiency syndrome-defining illness) by Kaplan-Meier analysis. Results. A total of 655 patients were observed for a median of 46 months (range, 13-72 months). The median change from baseline to most recent CD4+ cell count was +274 cells/μL, with 92% of patients having an increase in CD4+ cell count. By 6 years, the median CD4+ cell count was 493 cells/μ:L among patients with baseline CD4+ cell counts ≤200 cells/μL, 508 cells/μL among those with baseline CD4+ cell counts of 201-350 cells/μL, and 829 cells/μL among those with baseline CD4+ cell counts >350 cells/μL. In addition to baseline CD4+ cell count, injection drug use and older age were associated with a lesser CD4+ cell count response, and duration of therapy was associated with a greater CD4+ cell count response. Conclusion. Only patients with baseline CD4+ cell counts >350 cells//uL returned to nearly normal CD4 + cell counts after 6 years of follow-up. Significant increases were observed in all CD4+ cell count strata during the first year, but there was a lower plateau CD4+ cell count at lower baseline CD4 + cell strata. These data suggest that waiting to start HAART at lower CD4+ cell counts will result in the CD4+ cell count not returning to normal levels.