Improved outcomes with earlier initiation of highly active antiretroviral therapy among human immunodeficiency virus-infected patients who achieve durable virologic suppression: Longer follow-up of an observational cohort study

On the basis of studies with relatively short follow-up, treatment guidelines currently recommend that highly active antiretroviral therapy (HAART) be initiated in asymptomatic human immunodeficiency virus-infected patients when the CD4(+) lymphocyte count is less than or equal to200 cells/mm(3). We assessed the development of a new opportunistic infection or death among 1173 patients initiating HAART. Durable virologic suppression was defined as having more undetectable (<400 copies/mL) than detectable virus loads after the initiation of therapy. The median durations of therapy and follow-up were 29 and 36 months, respectively. Among patients who achieved durable virologic suppression, those with baseline CD4(+) lymphocyte counts of <200 cells/mm(3) tended to progress faster than those with baseline CD4(+) lymphocyte counts of 201-350 cells/mm(3) (P=.09) and progressed faster than those with baseline CD4(+) lymphocyte counts of >350 cells/mm(3) (P=.01). Among those with durable virologic suppression, there was no difference in disease progression between those with baseline CD4(+) lymphocyte counts of 201-350 cells/mm(3) and those with durable virologic suppression with baseline CD4(+) lymphocyte counts of >350 celld/mm(3) (P=.40). Initiating HAART with a CD4(+) lymphoctye count of <200 cells/mm(3) was associated with a higher risk of disease progression, even with durable virologic suppression. HAART should be initiated at CD4(+) lymphocyte counts of >200 cells/mm(3).