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hrsa

participating institutions:
Johns Hopkins University AIDS Service, New York State DOH AIDS Institute, The CORE Center, Cook County Hospital



NEWS AND NEW DEVELOPMENTS



Association of Initial CD4 Cell Count and Viral Load With Response to Highly Active Antiretroviral Therapy [Chaisson RE, et al. JAMA 2000;284:3128]: This is a retrospective analysis of the Moore Clinic Database to determine the relationship of baseline CD4 count and viral load with likelihood of response with a viral load <400 c/mL on at least one occasion within six months and "durable response," defined as no level >1,000 c/mL. The results showed a direct correlation between the CD4 cell count and the probability of initial response and durable response, and an inverse relationship between the viral load and initial response and durable response. Details are provided for the CD4 cell count at baseline in the following table:

Response to HAART Based on Baseline CD4 Count
CD4 strata
No. Initial response* Durable response**
>350/mm3 158 122 (77%) 61 (39%)
200 - 350/mm3 118 73 (62%) 34 (29%)
<200/mm3 271 153 (56%) 50 (19%)
* VL decrease to <400 c/mL
** VL <1,000 c/mL throughout observation period.


Comment: There is a current debate regarding the CD4 threshold to initiate antiretroviral therapy. Prior DHHS guidelines recommended treatment when the CD4 cell count was <500/mm3 and the viral load >10,000 - 20,000/mL [Ann Intern Med 1998;128:1079]. There has subsequently been a re-evaluation of the CD4 cell count threshold with the observation that no study has demonstrated clinical benefit with therapy initiated when the CD4 cell count was >350/mm3, and there is even some debate about benefit when the CD4 cell count is >200/mm3. An additional issue concerns the difficulty encountered with adherence and the long-term toxicity of antiretroviral agents. The result is a re-thinking of the indications to initiate therapy [JAMA 2000;283:381]. The study above is retrospective, but suggests that benefit in the form of viral load response is more likely with a CD4 cell count >350/mm3 when HAART is started. Unfortunately, there are no prior or on-going prospective studies that are designed to examine this issue specifically.
posted 1/18/2001




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