Olson, A;
Walker, AS;
Suthar, AB;
Sabin, C;
Bucher, H;
Jarriin, I;
Moreno, S;
... Ford, D; + view all
(2016)
Limiting cumulative HIV viremia copy years by early treatment reduces risk of AIDS and death.
Journal of Acquired Immune Deficiency Syndromes
, 73
(1)
pp. 100-108.
10.1097/QAI.0000000000001029.
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Abstract
BACKGROUND: Viremia copy-years (VCY), a time-updated measure of cumulative HIV exposure predicts AIDS/death; although its utility in deciding when to start combination antiretroviral therapy (cART) remains unclear. We aimed to assess the impact of initiating versus deferring cART on risk of AIDS/death by levels of VCY both independent of and within CD4 cell count strata ≥500 cells/mm3. / METHODS: Using CASCADE data, we created a series of nested –‘trials’ corresponding to consecutive months for individuals ≥16 years at seroconversion (SC) after 1995 who were cART-naïve and AIDS-free. Pooling across all ‘trials’, time to AIDS/death by CD4 and VCY strata was compared in those initiating vs. deferring cART using Cox models adjusted for: country, sex, risk group, SC year, age, time since last HIV-RNA, and current CD4, VCY, HIV-RNA, and mean number of previous CD4/HIV-RNA measurements/year. / RESULTS: Of 9,353 individuals, 5312 (57%) initiated cART and 486 (5%) acquired AIDS/died. Pooling CD4 strata, risk of AIDS/death associated with initiating vs. deferring cART reduced as VCY increased. In patients with high CD4 cell counts, ≥500 cells/mm3, there was a trend for a greater reduction for those initiating vs. deferring with increasing VCY (p = 0.09) with the largest benefit in the VCY ≥ 100,000 copy-years/mL group (HR (95% CI)= 0.41 (0.19, 0.87)). / CONCLUSIONS: For individuals with CD4 ≥500 cells/mm3, limiting the cumulative HIV burden to <100,000 copy-years/mL through cART may reduce the risk of AIDS/death, supporting recent START trial results suggesting immediate cART initiation vs. waiting until CD4 <350 cells/mm3.
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