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1 June 2008

Volume 46, Number 11
Clinical Infectious Diseases 2008;46:1751–1760
© 2008 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4611-0020$15.00
DOI: 10.1086/587900
HIV/AIDS MAJOR ARTICLE

Long‐Term Effects of Highly Active Antiretroviral Therapy on CD4+ Cell Evolution among Children and Adolescents Infected with HIV: 5 Years and Counting

Kunjal Patel,1,3

Miguel A. Hernán,1

Paige L. Williams,2,3

John D. Seeger,5

Kenneth McIntosh,4

Russell B. Van Dyke,6 and

George R. Seage III,1,3 for the

Pediatric AIDS Clinical Trials Group 219/219C Study Teama

Departments of 1Epidemiology and 2Biostatistics, Harvard School of Public Health, 3Center for Biostatistics in AIDS Research, and 4Harvard Medical School, Children’s Hospital, Boston, and 5i3 Drug Safety, Auburndale, Massachusetts; and 6Department of Pediatrics, Tulane University Health Sciences Center, New Orleans, Louisiana

Background.Lower percentages of CD4+ T lymphocytes are associated with adverse clinical outcomes among children and adolescents infected with human immunodeficiency virus (HIV). CD4+ lymphocyte percentage generally increases with receipt of highly active antiretroviral therapy (HAART), but long‐term follow‐up is required to assess whether these increases in CD4+ cell percentage are maintained and whether they lead to normal CD4+ cell percentages in children with severe immunosuppression.

Methods. The study population included 1236 children and adolescents perinatally infected with HIV who were enrolled in a US‐based multicenter prospective cohort study (Pediatric AIDS Clinical Trials Group 219/219C) and who were not receiving HAART at study initiation. We estimated the effects of HAART, HAART with protease inhibitors, and HAART with nonnucleoside reverse‐transcriptase inhibitors on CD4+ cell percentage, using marginal structural models to account for confounding by severity.

Results.Initiation of any type of HAART increased CD4+ cell percentage by 2.34% (95% confidence interval, 1.35%–3.33%) in the first year, relative to noninitiation of HAART. The substantial increases in CD4+ cell percentage observed after the first year of experience with these combination therapies were followed by relatively smaller increases that continued for 5 years after initiation. Although larger increases in CD4+ cell percentage were observed among children with a greater degree of immunosuppression at baseline, the mean CD4+ cell percentage after 5 years of HAART did not reach normal levels.

Conclusions.Our study supports the initiation of HAART in children before severe immunosuppression occurs for long‐term maintenance of normal CD4+ cell percentages. This beneficial result must be weighed against the evidence of potential adverse events associated with the prolonged use of such therapy.

Received 1 November 2007; accepted 15 January 2008; electronically published 21 April 2008.

Reprints or correspondence: Dr. Kunjal Patel, 677 Huntington Ave., Dept. of Epidemiology, Harvard School of Public Health, Boston, MA 02115 ().

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