No Excess Death Among HIV-Infected People -- as Long as CD4+ Cell Counts Are Kept Close to Normal

David Wohl, M.D.

Life expectancy for people living with HIV has been steadily rising -- approaching, but not quite achieving, that of the uninfected population in most studies. But such data have been limited in that they have tended to look at all comers, including those presenting with more advanced HIV disease.

That is, until this study, which was published in the March 13 issue of AIDS and authored by Alison J. Rodger, M.D., of University College London, and colleagues.

This analysis compared the rate of death among HIV-infected patients with relatively preserved or reconstituted immune function with that of the general population. It found that, for those with a CD4+ cell count >500 cells/mm3, there was no excess mortality. Details include:

  • Analysis used the control participants (N=3,280) in the SMART (intermittent ART vs. continuous ART) and ESPRIT (IL-2 plus ART vs. ART alone) cohorts. All had suppressed viremia and a CD4+ cell count >350 cells/mm3, and were not injection drug users.
  • Median age = 43 years; median nadir CD4+ cell count prior to study participation = 228 cells/mm3 (25% had a history of AIDS), and median CD4+ cell count at study randomization = 535 cells/mm3.
  • There were 62 deaths; only two were determined to be AIDS-related.
  • Mortality rate was increased compared to the general population among HIV-infected patients with a CD4+ cell count between 350 and 499 cells/mm3 (SMR 1.77; 95% CI: 1.17, 2.55). However, there was no evidence for increased mortality with a CD4+ cell count >500 cells/mm3 (SMR 1.00; 95% CI: 0.69, 1.40).

It can be speculated that long-term inflammation could cause life-threatening disease, and that this is reduced with effective HIV treatment. These results suggest that a normal CD4+ cell count equals a normal risk of death -- and they punctuate the point that a normal CD4+ cell count is not below 500 cells/mm3.

Foremost, the finding of an increased risk of mortality at counts below 500 cells/mm3 adds further support for early initiation of HIV therapy.

The Study: Rodger A, Lodwick R, Schechter M, et al. Mortality in well controlled HIV in the continuous antiretroviral therapy arms of the SMART and ESPRIT trials compared with the general population. AIDS 2013; 27:973-979.

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