title: The clinical impact of continuing to prescribe antiretroviral therapy in patients with advanced AIDS who manifest no virologic or immunologic benefit.
abstract: BACKGROUND
  Despite the efficacy and tolerability of modern antiretroviral therapy (ART), many patients with advanced AIDS prescribed these regimens do not achieve viral suppression or immune reconstitution as a result of poor adherence, drug resistance, or both. The clinical outcomes of continued ART prescription for such patients have not been well characterized.
  
  
  METHODS
  We examined the causes and predictors of all-cause mortality, AIDS-defining conditions, and serious non-AIDS-defining events among a cohort of participants in a clinical trial of pre-emptive therapy for CMV disease. We focused on participants who, despite ART had failed to achieve virologic suppression and substantive immune reconstitution.
  
  
  RESULTS
  233 ART-receiving participants entered with a median baseline CD4+ T cell count of 30/mm(3) and plasma HIV RNA of 5 log10 copies/mL. During a median 96 weeks of follow-up, 24.0% died (a mortality rate of 10.7/100 patient-years); 27.5% reported a new AIDS-defining condition, and 22.3% a new serious non-AIDS event. Of the deaths, 42.8% were due to an AIDS-defining condition, 44.6% were due to a non-AIDS-defining condition, and 12.5% were of unknown etiology. Decreased risk of mortality was associated with baseline CD4+ T cell count ≥25/mm(3) and lower baseline HIV RNA.
  
  
  CONCLUSIONS
  Among patients with advanced AIDS prescribed modern ART who achieve neither virologic suppression nor immune reconstitution, crude mortality percentages appear to be lower than reported in cohorts of patients studied a decade earlier. Also, in contrast to the era before modern ART became available, nearly half of the deaths in our modern-era study were caused by serious non-AIDS-defining events. Even among the most advanced AIDS patients who were not obtaining apparent immunologic and virologic benefit from ART, continued prescription of these medications appears to alter the natural history of AIDS--improving survival and shifting the causes of death from AIDS- to non-AIDS-defining conditions.
authors.affiliation: University of North Carolina, Chapel Hill, North Carolina, United States of America.
authors.forename: David A
authors.initials: DA
authors.lastname: Wohl
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Kendall
authors.forename: Judith
authors.initials: J
authors.lastname: Feinberg
authors.forename: Beverly
authors.initials: B
authors.lastname: Alston-Smith
authors.forename: Susan
authors.initials: S
authors.lastname: Owens
authors.forename: Suzette
authors.initials: S
authors.lastname: Chafey
authors.forename: Michael
authors.initials: M
authors.lastname: Marco
authors.forename: Sharon
authors.initials: S
authors.lastname: Maxwell
authors.forename: Constance
authors.initials: C
authors.lastname: Benson
authors.forename: Philip
authors.initials: P
authors.lastname: Keiser
authors.forename: Charles
authors.initials: C
authors.lastname: van der Horst
authors.forename: Mark A
authors.initials: MA
authors.lastname: Jacobson
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000097:blood / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality*; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D024882:Drug Resistance, Viral; D005260:Female; D005500:Follow-Up Studies; D015497:HIV-1; D006801:Humans; D008297:Male; D055118:Medication Adherence; D012367:RNA, Viral / Q000097:blood / Q000276:immunology; D015996:Survival Rate
chemical_list: D044966:Anti-Retroviral Agents; D012367:RNA, Viral