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

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Abstract
There 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/μL; however, the role of antiretroviral adherence on CD4 cell count responses has not been well evaluated. We 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/μL) and adherence. Among patients starting HAART with <50 cells/μL, during the fifth 15-week period after the initiation of HAART, absolute CD4 cell counts were 200 cells/μL (interquartile range [IQR]: 130–290) for adherent patients versus 60 cells/μL (IQR: 10–130) for nonadherent patients. Similarly, among patients starting HAART with 50 to 199 cells/μL, during the fifth 15-week period after the initiation of HAART, absolute CD4 cell counts were 300 cells/μL (IQR: 180–390) versus 125 cells/μL (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/μL from baseline (relative hazard [RH] = 2.88, 95% confidence interval [CI]: 2.46–3.37). Among patients with baseline CD4 cell counts 200 cells/μL (RH = 4.85, 95% CI: 3.15–7.47). These 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.