Long-term evolution of CD4(+) cell count in patients under combined antiretroviral therapy

Objective: Combined antiretroviral treatment (cART) results in profound immunologic improvement, but it is unclear whether CD4(+) cell counts return to levels similar to those of HIV-negative individuals. We explore long-term CD4(+) cell count evolution post-cART and its association with baseline levels, virologic suppression, pre-cART cumulative viremia and other factors. Design: Data were derived from the AMACS. Included individuals were adults who started cART, at least 2003, while previously ART-naive. Methods: Changes in CD4(+) cell counts were modeled through piecewise linear mixed models. Results: A total of 3405 individuals were included. The majority was male (86.0%), homosexual (58.8%) with median (IQR) age at cART initiation 36 (31-44) years and a median (IQR) follow-up of 3.9 (2.0-6.9) years. Most persons (57%) starting cART with less than 200 cells/mu l did not reach 600 cells/mu l after 7 years of treatment. Those starting cART with 200-349 CD4(+) cells/mu l could reach 600 cells/mu l within less than 2 years of fully suppressive treatment. Probability of CD4(+) normalization (i.e. > 800 cells/mu l) after 7 years of suppressive treatment was 24 and 46% for those starting treatment with less than 200 or 200-349 CD4(+) cells/mu l, respectively. Lower pre-cART cumulative viremia was associated with faster CD4(+) recovery. CD4(+) cell count increases after 4 years were either insignificant or very slow, irrespectively of baseline levels. Conclusion: cART initiation before CD4(+) cell count drops below 350 cells/mu l is crucial for achieving normal CD4(+) levels. These findings underline the importance of timely diagnosis and cART initiation as the risk of both AIDS and non-AIDS-related morbidity/mortality remains increased in patients with incomplete CD4(+) recovery. Copyright (C) 2019 Wolters Kluwer Health, Inc. All rights reserved.