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The Impact of Adherence on CD4 Cell Count Responses Among HIV-Infected Patients

BackgroundThere have been concerns that irreversible immune damage may result if highly active antiretroviral therapy (HAART) is initiated after the CD4 cell count declines to below 350 cells/&mgr;L; however, the role of antiretroviral adherence on CD4 cell count responses has not been well evaluated. MethodsWe evaluated CD4 cell count responses of 1522 antiretroviral-naive patients initiating HAART who were stratified by baseline CD4 cell count (<50, 50–199, and ≥200 cells/&mgr;L) and adherence. ResultsAmong patients starting HAART with <50 cells/&mgr;L, during the fifth 15-week period after the initiation of HAART, absolute CD4 cell counts were 200 cells/&mgr;L (interquartile range [IQR]: 130–290) for adherent patients versus 60 cells/&mgr;L (IQR: 10–130) for nonadherent patients. Similarly, among patients starting HAART with 50 to 199 cells/&mgr;L, during the fifth 15-week period after the initiation of HAART, absolute CD4 cell counts were 300 cells/&mgr;L (IQR: 180–390) versus 125 cells/&mgr;L (IQR: 40–210) for nonadherent patients. In Cox regression analyses, adherence was the strongest independent predictor of the time to a gain of ≥50 cells/&mgr;L from baseline (relative hazard [RH] = 2.88, 95% confidence interval [CI]: 2.46–3.37). Among patients with baseline CD4 cell counts <200 cells/&mgr;L, adherence was the strongest independent predictor of the time to a CD4 cell count >200 cells/&mgr;L (RH = 4.85, 95% CI: 3.15–7.47). ConclusionsThese data demonstrate that substantial CD4 gains are possible among highly advanced adherent patients and should contribute to the ongoing debate over the optimal time to initiate HAART.