The relative prognostic value of plasma HIV RNA levels and CD4 lymphocyte counts in advanced HIV infection

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Objective:It has been suggested that the plasma HIV RNA level is a better predictor of AIDS and death than the CD4 lymphocyte count. We assessed whether the prognostic value of plasma virus levels was different according to the CD4 count.Design:Prospective cohort study of HIV-infected patients followed for a median of 2.91 years (range, 0.02–4.54).Setting:Department of Infectious Diseases at Rigshospitalet, Copenhagen, Denmark.Participants:A group of 255 HIV-infected individuals with an initial measurement of CD4 lymphocyte count and plasma HIV RNA.Main outcome measure:Survival time.Results:The plasma HIV RNA (median 101 410 copies/ml; range (range 200–7 200 000) and the CD4 lymphocyte count (median 250 cells × 106/l; range 1–1247) were negatively correlated (Pearson r = −0.53; P < 0.00001). Of the 255 patients, 110 died during follow-up. Overall, a higher HIV RNA level was associated with increased risk of death, but the association was smaller in patients with lower CD4 lymphocyte counts (test for interaction P < 0.0001). In patients with CD4 count below 50 cells × 106/l the association between HIV RNA and risk of death was not statistically significant (relative hazard per 10-fold higher HIV RNA level was 1.53; P = 0.11; adjusted for age and CD4 count) while that between the CD4 count and risk of death was highly significant (relative hazard per 50% lower CD4 count 1.38; P = 0.005; adjusted for age and HIV RNA level).Conclusions:Patients were relatively lightly treated with antiretroviral drugs both before and during this study. In this situation, it appears that the HIV RNA level has a relatively weak association with risk of death in patients with advanced HIV infection and that the CD4 lymphocyte count is probably more useful in assessing prognosis.

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