809. Growth in the Population of Antiretroviral Therapy (ART)-Nave Persons with High CD4 Counts: An Expanding Clinical and Public Health Dilemma
Session: Abstracts: Oral Abstract Session: HIV Complications and Pathogenesis
Friday, October 22, 2010: 3:45 PM
118-120
Background: A goal of routine HIV screening is to facilitate entry into HIV care early in the course of infection, and updated US HIV treatment guidelines recommend initiating ART at higher CD4 counts than previously.

Methods: We evaluated the size and characteristics of the HIV-infected, ART-naïve population in the CFAR Network of Integrated Clinical Systems (CNICS). We selected the nadir CD4 count in each year for each subject who entered CNICS on or after January 1, 1997 and examined ART initiation by 3 months post-nadir. We used chi-square tests to assess trends over time and generalized estimating equations to assess factors associated with new eligibility for ART (ART naïve with nadir CD4 351-500 and separately, CD4>500) compared to previous eligibility (ART-naïve with nadir CD4≤350 or prior ART initiation).

Results: 6,228 persons were seen in 24,844 visits at 4 sites in 1997-2007. Of 3,653 subjects in the cohort in 2007, 672 (18%) were ART-naïve: 326 (49%) with nadir CD4 ≤350, 186 (28%) with nadir CD4 351-500, and 160 (24%) with nadir CD4 >500. From 1997 to 2007, among ART-naïve persons, the number with nadir CD4 ≤350 increased 4.4-fold (74 to 326), the number with nadir CD4 351-500 increased 6.6-fold (28 to 186), and the number with nadir CD4 >500 increased 6.2-fold (26 to 160). The total number of subjects new to the cohort each year was relatively stable over time (mean n = 454 SD±42). Of the new subjects, the proportion who did not initiate ART with nadir CD4 ≤350 was stable from 1997 to 2007 [mean: 17% (n=79) of total per year; p=0.4], whereas the proportion who did not initiate ART with nadir CD4 351-500 grew from 7% (n=25) to 15% (n= 61) (p<0.001), and the proportion who did not initiate ART with nadir CD4 >500 grew from 7% (n=25) to 14% (n=79) (p=0.002).  In multivariate analysis, persons newly eligible for ART were younger than those who were previously eligible, but did not differ significantly by gender, race/ethnicity, or HIV acquisition risk factor.

Conclusion: The size of the ART-naïve population with relatively high CD4 counts is rapidly increasing. New guidelines support initiating ART for a substantial portion of these persons, but the best ART initiation strategy in this population remains ill-defined.  This uncertainty has clinical and public health implications.


Subject Category: H. HIV/AIDS and other retroviruses

Speakers:
Julia C. Dombrowski, MD, MPH , Medicine/Infectious Diseases, University of Washington and Public Health - Seattle & King County, Seattle, WA
Mari M. Kitahata, MD , Medicine/Infectious Diseases, University of Washington, Seattle, WA
Katherine K. Thomas, MS , Biostatistics, University of Washington, Seattle, WA
Heidi Crane, MD , Medicine/Infectious Diseases, University of Washington, Seattle, WA
Matthew R. Golden, MD, MPH , Medicine/Infectious Diseases, University of Washington and Public Health - Seattle and King County, Seattle, WA

Disclosures:

J. C. Dombrowski, None

M. M. Kitahata, Yes
Gilead Sciences, Inc: Consultant,

K. K. Thomas, None

H. Crane, None

M. R. Golden, Yes
Pfizer: Grant Investigator, Free medication for patients

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