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Date Posted: 18:31:36 07/24/02 Wed
Author: moonotter
Subject: Low CD4+ Count at Start of Treatment Predicts Poor Outcome in HIV Patients

Low CD4+ Count at Start of Treatment Predicts Poor Outcome in HIV Patients


Reuters Health Information 2002. © 2002 Reuters Ltd.
Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.


By Deborah Mitchell
BARCELONA, Spain (Reuters Health) Jul 09 - In treatment-na ve HIV-infected patients, baseline CD4+ T lymphocyte count, rather than viral load, appears to be the key prognostic factor following initiation of highly active antiretroviral therapy (HAART), according to several reports presented here at the XIV International AIDS Conference.

Exactly when to initiate HAART still remains a significant question for clinicians treating HIV-infected patients. Tuesday morning, several multinational teams presented data to help answer this question.

"CD4+ at baseline was the most strongly predictive factor" of patient prognosis, Dr. Genevieve Chene of the University of Bordeaux, France, told conference attendees. Dr. Chene and members of the ART Cohort Collaboration evaluated the results of 13 cohort studies conducted in Europe and North America.

At baseline, all 12,574 HIV-infected subjects were treatment-na ve before starting HAART with three drugs: two nucleotide reverse transcriptase inhibitors plus a protease inhibitor (PI) or a nonnucleoside reverse transcriptase inhibitor (NNRTI).

The median baseline CD4+ count was 250 cells/ L and median viral load was 4.9 log10 copies/mL. The median age was 38 years, and 21% of the patients were women. The combined study endpoints were time to AIDS or death.

At 3-year followup, there were 870 AIDS-related events and 344 deaths.

Patients with baseline CD4+ levels greater than 350 cells/ L had the best prognosis. However, there was only a "small absolute difference between patients who started HAART with >350 counts and those with 200 to 349 counts," Dr. Chene said.

Baseline viral load was only predictive if it was >5 log10 at baseline. After 6 months of HAART, viral load was predictive at all levels. Other patient factors that predicted outcome at 3 years included age >50 years, a history of injection drug use and stage C disease at baseline.

Overall, patient prognosis after HAART initiation varied widely, depending on CD4+ cell counts at baseline and at 6 months, Dr. Chene said. She also stressed the importance of taking into account each individual patient's response to therapy.

"These type of data are now needed in the developing world," she added.

The study findings are scheduled for publication in The Lancet.

In a second presentation, Dr. John T. Brooks reported the findings from the Adult and Adolescent Spectrum of HIV Disease Working Group on behalf of his team at the US Centers for Disease Control and Prevention in Atlanta. They evaluated the effect of baseline CD4+ cell count on the outcome of patients with no known history of antiretroviral therapy who began HAART after 1996.

Of 1464 subjects, data were evaluated for 583 who initially responded to HAART. Of these patients, Dr. Brooks found that 56 developed virologic failure, defined as a >0.5 log10 increase from viral load nadir after HAART initiation, followed by a second elevated viral load measurement or a change in antiretroviral therapy.

Patients with baseline CD4+ cell counts between 0-199 cells/ L had more than 10 times the risk of treatment failure compared with those with CD4+ cell counts >350 cells/ L. Patients with CD4+ counts between 200 and 349 cells/ L were twice as likely to fail HAART compared with those with higher levels.

Based on these findings, a more durable HAART response appears to be achieved by patients with CD4+ counts >350 cells/ L at baseline, Dr. Brooks said.

In another report, Dr. Robert S. Hogg and colleagues at the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, evaluated the mortality risk associated with intermittent HAART use and the use of a regimen that included an NNRTI instead of a protease inhibitor.

The population-based study included 1416 treatment-na ve, HIV-infected adults who began therapy between 1996 and 2000. Thirty-one percent started an NNRTI-containing regimen.

Multivariate results indicated that baseline CD4+ counts below 200 cells/ L, intermittent use of HAART and older age were the only factors independently associated with predicted mortality, he told conference participants. Regimens with "NNRTI and PIs were associated with similar outcomes."



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