Long-Term Clinical Outcome of Human Immunodeficiency Virus-Infected Patients with Discordant Immunologic and Virologic Responses to a Protease Inhibitor-Containing Regimen [Piketty C, et al. JID 2001;183:1328]: This is a report from Paris concerning a cohort of 150 HIV-infected patients who began a PI-based HAART regimen in 1996. Results were analyzed based on virologic response and CD4 cell count response. The former was defined as a decrease in HIV RNA level by 1 log or greater, and the CD4 cell response was defined as an increase at 12 months from the baseline of <100/mm³. Using this definition, 90 patients responded by both parameters, and 18 were negative/negative. There were 42 with discordant responses, including 28 with increases in CD4 cell count/negative virologic response and 14 with immunologic failure plus virologic response. Outcome was evaluated by the frequency of AIDS-defining events or death during an average of 30 months of observation and correlated with the four outcomes defined above at 12 months. The results are shown in the table below:

The authors conclude that the CD4 cell response is more important than viral load in predicting clinical outcome.
Comment: This is an interesting report, but it's hard to know what to do with the data. It is not surprising that the CD4 cell count response was more important than viral load in determining prognosis according to clinical events. Guidelines are based primarily on viral load responses and changes are recommended based on suboptimal virologic response. Unfortunately, there are few or no data to indicate that changes in HAART regimens will deal effectively with discordant responses when the CD4 cell count fails to increase.
posted 5/16/2001

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