Predictors of long-term response to protease inhibitor therapy in a cohort of HIV-infected patients

Objective: To assess the rate of long-term effectiveness and factors associated with response to protease inhibitor therapy in a cohort of HIV-infected patients. Design and setting: Prospective, non-randomized study in a tertiary care centre. Patients: A total of 400 HIV-infected patients who started on protease inhibitor therapy (saquinavir, 28%; ritonavir, 26%; indinavir, 46%) from March 1996 to March 1997. Main outcomes measures: Long-term virological and immunological effectiveness were defined as HIV RNA levels below 200 copies/ml and CD4+ cell count increase greater than 100 x 10(6)/l, respectively, after 12 months of therapy. Results: Fifty-seven per cent of patients had a prior AIDS-defining illness, and 91% had received nucleoside analogues for a median time of 28 months. Median CD4+ count was 86 x 10(6) cells/l and HIV RNA level was 4.46 log(10) copies/ml. The global rate of virological and immunological effectiveness at 1 year was 45 and 59%, respectively. In a logistic regression analysis, treatment failure was associated with higher baseline HIV load [relative risk (RR), 2.10; P < 0.01], prior antiretroviral therapy (RR, 2.07; P < 0.01), and use of saquinavir (RR, 1.55; P = 0.03), whereas a reduction of more than 1 log(10) in HIV load within the first 3 months on therapy was strongly associated with response (RR, 0.65; P < 0.01). There was no strict correlation between virological and immunological effectiveness (r = -0.35; P = 0.01). Conclusions: Nearly half of the patients maintain undetectable HIV load after 1 year of therapy, although important immunological benefit can be obtained in a greater proportion of patients. These data suggest the use of the most potent antiretroviral therapy in pretreated patients with high HIV load, and the capacity of initial virological decline to predict the long-term outcome. (C) 1998 Lippincott-Raven Publishers.