A critical assessment of the prognostic value of HIV-1 RNA levels and CD4+ cell counts in HIV-infected patients

Objective: To determine to what extent human immunodeficiency type 1 (HIV-1) RNA levels and CD4(+) cell counts predict clinical outcomes in a general HIV-1-infected population. Methods: Community-based prospective study (Swiss HIV Cohort Study) including 394 HIV-1-infected patients, randomly selected from 4 strata of CD4(+) cell counts (0 to <0.05, 0.05 to <0.20, 0.20 to <0.50, and greater than or equal to 0.50 X 10(9)/L). Levels of HIV-1 RNA, CD4(+) cell counts, and other variables were evaluated from samples collected between 1991 and 1993 for their ability to predict death and clinical progression. Results: Patients were followed up on average for 29 months. Baseline HIV-1 RNA levels, CD4(+) cell counts, clinical stage, and beta(2)-microglobulin levels independently predicted survival, whereas only HIV-1 RNA levels and CD4(+) cell counts independently predicted clinical progression. Multivariate relative hazards (RHs) for death ranged from 1.0 to 5.4 across quartiles of CD4(+) counts, but only from 1.0 to 1.8 across quartiles of HIV-1 RNA. For clinical progression, gradients of risk were similar for CD4(+) counts (1.0-4.2) and for HIV-1 RNA (1.0-3.1). In patients with CD4(+) cell counts less than 0.05 X 10(9)/L, HIV-1 RNA levels predicted neither death nor clinical progression. Finally, the number of HIV-1 RNA copies per CD4(+) cell was the best predictor of death (multivariate RH, 1.0-9.7 across quartiles) and clinical progression (multivariate Conclusions: Levels of HIV-1 RNA and CD4(+) cell counts provided independent and complementary information on clinical outcomes. The RNA/CD4(+) ratio was the best single predictor. In patients who had fewer than 0.05 X 10(9)/L CD4(+) cells, HIV-1 RNA levels had little prognostic value.