- 84: Lancet. 2002 Jul 13;360(9327):119-29
Prognosis of HIV-1-infected patients starting highly active
antiretroviral therapy: a collaborative analysis of prospective
studies.
Egger M, May M, Chêne G, Phillips AN, Ledergerber B, Dabis F,
Costagliola D, D'Arminio Monforte A, de Wolf F, Reiss P, Lundgren JD,
Justice AC, Staszewski S, Leport C, Hogg RS, Sabin CA, Gill MJ,
Salzberger B, Sterne JA; ART Cohort Collaboration.
Department of Social and Preventive Medicine, University of Bern,
CH-3012 Bern, Switzerland. egger@ispm.unibe.ch
Erratum in:
Lancet 2002 Oct 12;360(9340):1178.
Abstract
BACKGROUND: Insufficient data are available from single cohort
studies to allow estimation of the prognosis of HIV-1 infected,
treatment-naive patients who start highly active antiretroviral
therapy (HAART). The ART Cohort Collaboration, which includes 13
cohort studies from Europe and North America, was established to
fill this knowledge gap. METHODS: We analysed data on 12,574 adult
patients starting HAART with a combination of at least three drugs.
Data were analysed by intention-to-continue-treatment, ignoring
treatment changes and interruptions. We considered progression to a
combined endpoint of a new AIDS-defining disease or death, and to
death alone. The prognostic model that generalised best was a
Weibull model, stratified by baseline CD4 cell count and
transmission group. FINDINGS During 24,310 person-years of follow
up, 1094 patients developed AIDS or died and 344 patients died.
Baseline CD4 cell count was strongly associated with the probability
of progression to AIDS or death: compared with patients starting
HAART with less than 50 CD4 cells/microL, adjusted hazard ratios
were 0.74 (95% CI 0.62-0.89) for 50-99 cells/microL, 0.52
(0.44-0.63) for 100-199 cells/microL, 0.24 (0.20-0.30) for 200-349
cells/microL, and 0.18 (0.14-0.22) for 350 or more CD4 cells/microL.
Baseline HIV-1 viral load was associated with a higher probability
of progression only if 100,000 copies/microL or above. Other
independent predictors of poorer outcome were advanced age,
infection through injection-drug use, and a previous diagnosis of
AIDS. The probability of progression to AIDS or death at 3 years
ranged from 3.4% (2.8-4.1) in patients in the lowest-risk stratum
for each prognostic variable, to 50% (43-58) in patients in the
highest-risk strata. INTERPRETATION: The CD4 cell count at
initiation was the dominant prognostic factor in patients starting
HAART. Our findings have important implications for clinical
management and should be taken into account in future treatment
guidelines.