Late presentation for HIV impairs immunological but not virological response to antiretroviral treatment

OBJECTIVES To study the impact of late presentation (CD4 <350 cells/μL or an AIDS-defining event) on effectiveness and safety of initial ART and to evaluate whether treatment response depends on first-line ART regimen in late presenters (LP). DESIGN ART-naïve adults from the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) starting triple ART between 2010 and 2018. METHODS We used multivariable models to assess differences in viral suppression (VS, viral load <50 copies/mL), immunological response (IR, change in CD4 count, CD4% (>29%) and CD4/CD8 normalization (>0.4 and >1) multiple T-cell marker recovery (MTMR): CD4+ >500 cells/μL plus CD4% >29% plus CD4/CD8 >1), and treatment discontinuation due to adverse events (TDAE) at 48 weeks from ART initiation. RESULTS Of 8,002 participants, 48.7% were LP. Of them 45.8% initiated ART with a NNRTI- (mostly TDF/FTC/EFV), 33.9% with a PI- (mostly TDF/FTC+boosted DRV) and 20.3% with an INI-based regimen (mostly ABC/3TC/DTG). At 48 weeks, LP had similar VS, but worse IR, than non-LP with no difference on TDAE. LP initiating with NNRTI- based regimens were more likely to achieve VS than those starting with INI-based, due to the higher chance of achieving VS observed with TDF/FTC/RPV compared to ABC/3TC/DTG. Initial treatment with NNRTI- or PI-based showed similar IR than the INI-based regimens, which showed lower rates of TDAE than NNRTI- and PI-based regimens. CONCLUSIONS Despite safety and effectiveness of initial ART in terms of VS, LP may not experience complete IR. In LP, effectiveness and safety depends on both the class and the specific first-line ART regimen.

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