title: Effect of medication adherence on survival of HIV-infected adults who start highly active antiretroviral therapy when the CD4+ cell count is 0.200 to 0.350 x 10(9) cells/L.
abstract: BACKGROUND
  The safety of delaying highly active antiretroviral therapy (HAART) in HIV-infected patients is uncertain when the CD4+ cell count declines below 0.350 x 10(9) cells/L.
  
  
  OBJECTIVE
  To evaluate the effect of baseline CD4+ cell count and adherence to HAART on survival rates.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  Province-wide Canadian HIV/AIDS treatment program.
  
  
  METHODS
  1422 HIV-infected persons initiating HAART between 1 August 1996 and 31 July 2000 and followed through 31 March 2002.
  
  
  METHODS
  Patients were stratified by baseline CD4+ cell count and adherence level. Cumulative mortality rates were evaluated by using Kaplan-Meier methods and Cox regression-estimated adjusted relative hazards.
  
  
  RESULTS
  Kaplan-Meier analyses showed no survival benefit of starting HAART at a CD4+ count of 0.200 x 10(9) cells/L or greater among adherent patients. Adjusted analysis showed that compared with adherent patients who initiated HAART at a CD4+ cell count of 0.350 x 10(9) cells/L or greater, nonadherent patients who initiated HAART when the CD4+ cell count was 0.200 to 0.349 x 10(9) cells/L had statistically elevated mortality rates (adjusted relative hazard, 2.56 [95% CI, 1.36 to 4.84]; P = 0.004). However, compared with adherent patients who initiated HAART at a CD4+ cell count of 0.350 x 10(9) cells/L or greater, adherent patients who initiated HAART when the CD4+ cell count was 0.200 to 0.349 x 10(9) cells/L had statistically similar mortality rates (adjusted relative hazard, 0.82 [CI, 0.45 to 1.49]; P > 0.2).
  
  
  CONCLUSIONS
  Delaying HAART until the CD4+ cell count falls to 0.200 x 109 cells/L does not increase the mortality rate in HIV-infected patients with good medication adherence. Mortality rates increase if HAART is initiated below 0.200 x 10(9) cells/L. Also, nonadherent patients have higher mortality rates than adherent patients with similar CD4+ cell counts. Above a CD4+ cell count of 0.200 x 10(9) cells/L, medication adherence is the critical determinant of survival, not the CD4+ cell count at which HAART is begun.
authors: St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
authors: Evan
authors: E
authors: Wood
authors: Robert S
authors: RS
authors: Hogg
authors: Benita
authors: B
authors: Yip
authors: P Richard
authors: PR
authors: Harrigan
authors: Michael V
authors: MV
authors: O'Shaughnessy
authors: Julio S G
authors: JS
authors: Montaner
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D002170:Canada; D002423:Cause of Death; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology* / Q000401:mortality; D006801:Humans; D015993:Life Tables; D008297:Male; D010349:Patient Compliance; D011446:Prospective Studies; D012044:Regression Analysis; D013997:Time Factors