What are the adverse effects of delay in antiretroviral therapy (ART) for HIV infection?

Updated: Jul 27, 2020
  • Author: Shelley A Gilroy, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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An analysis of a series of 18 prospective cohort studies in the United Kingdom found that deferring combination antiretroviral therapy until patients reached a CD4 cell count of 251-350 cells/μL was associated with higher rates of AIDS and death than starting therapy at 351-450 cells/μL. The adverse effect of deferring treatment increased with decreasing CD4 cell count threshold. The researchers suggested than the minimum threshold for initiating treatment should be 350 CD4+ T cells/μL rather than 200/μL. [114]

This finding was echoed in a Haitian study (a resource-limited setting), where early initiation of antiretroviral therapy significantly decreased the rates of death and incident tuberculosis. Initiating antiretroviral therapy treatment during early phases of disease (CD4+ T-cell count between 200/μL and 350/μL) was found to increase survival in Haitians compared with waiting until CD4+ T cells fell below 200/μL. [115]

The HIV-CAUSAL Collaboration analyzed data from the United States Veterans Health Administration and HIV clinics in Europe to compare the results of therapy initiation at CD4 cell counts from 0.200-0.500 × 109 cells/L. The study concluded that initiating HAART therapy at the 0.350 × 109 cells/L threshold decreased AIDS-free survival compared with initiation at 0.500 × 109 cells/L, but did not substantially increase mortality. A significant rise in mortality was seen at initiation thresholds below 0.300 × 109 cells/L. This result differs from other studies. Because CD4 cell count at initiation is not randomized in such observational cohort studies, confounding factors may exist. [116]

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