One year survival of HIV-infected veterans with CD4 B100 cells/mm 3 : data from a veteran cohort Katharine Breaux a,b *, Susmitha Gadde b , Edward A. Graviss c,d and Maria C. Rodriguez-Barradas a,b a DepartmentofInfectiousDiseases,MichaelE.DeBakeyVeteransAffairsMedicalCenter,Houston,TX,USA; b Departmentof Infectious Diseases, Baylor College of Medicine, Houston, TX, USA; c Center for Molecular and Translational Research, The Methodist Hospital Research Institute, Houston, TX, USA; d Department of Pathology, Baylor College of Medicine, Houston, TX, USA (Received 24 April 2009; final version received 19 November 2009) Survival among HIV-infected patients markedly improved with the introduction of highly active antiretroviral therapy (HAART). Easier to take and more effective HAART options have improved the one year virologic success rate among naı¨ve patients. Numerous studies have shown that initiating HAART and restoration of CD4 cells positively impact survival. There are only a few evaluations that have been carried out on the changes in survival among patients who are severely immunosuppressed. We evaluated survival among a cohort of veterans with CD4 B100 cells/mm 3 (CD4 B100) in three time periods reflecting early, mid, and recent HAART. Using the HIV clinic database, all patients with CD4 B100 seen between 1996 and 2004 were identified (n 394). Patients entered Cohorts 1 (n 219), 2 (n 72), and 3 (n 103) in 19961998, 19992001, and 20022004, respectively. Data on demographics, AIDS-defining illnesses, co-morbidities, treatment, CD4, and viral load (VL) were abstracted. Survival analysis controlling for the above variables was performed and odds ratios with 95% confidence intervals were calculated. Rate of virologic suppression was higher for Cohort 2 when compared to Cohort 1 (63% vs. 46%, p B0.05), but lower for Cohort 3 when compared to Cohort 2 (49%, p B0.05). Survival at one year was high for Cohorts 1 and 2 (9295%), but significantly lower in Cohort 3 (80%). On logistic regression analysis and for the whole cohort, HAART use, achieving a CD4 200 and VL B400 were independent predictors of survival. Older age at cohort entry and having a diagnosis of lymphoma, Mycobacteriumaviumcomplex infection, coronary artery disease, or renal insufficiency were negative predictors. In the most recent HAART period 20022004, one year survival after CD4 B100 significantly decreased in spite of availability of specialized HIV clinical and support services and antiretrovirals. Our results suggest that more than better drugs are needed for improving survival among certain patient populations with advanced immunosuppression. Keywords: CD4; AIDS; survival; US veterans Introduction HIV-infected patients with a CD4 cell count B100 cells/mm 3 (CD4 B100) have the highest risk for AIDS-defining events. Widespread use of highly active antiretroviral therapy (HAART) has improved survival in this patient population (Hooshyar et al., 2007). The percentage of treatment-naı¨ve patients achieving viral suppression after one year of HAART has improved from 5060% to about 8090% in the most recent years, even in inner city clinic popula- tions (Bartlett et al., 2006; Moore, Keruly, Gebo, & Lucas, 2005). Improved virological response has also been observed among treatment-naı¨ve HIV-infected individuals within the Veterans Administration (VA) system (Braithwaite et al., 2007); the odds ratio (OR) of viral suppression after one year of treatment improved for those who started treatment in 1998, 2000, 2001, and after 2001 compared with those who started in 1997 and before 1997 (OR of 1.37, 1.62, and 1.72, respectively; P B0.01). The observed im- proved response rates among the different recent cohorts may be explained by increased availability of potent antiretroviral agents, improved dosing sche- dules, improved side effect profiles, and emphasis on interventions that improve medication adherence. In countries with widespread access to HAART, the survival of newly diagnosed HIV-infected patients is approaching that of the general population (Bhavan, Kampalath, & Overton, 2008). Within the VA health care system, all HIV- infected subjects have access to comprehensive primary care and to all available antiretroviral drugs; once enrolled in the VA the majority of patients use VA services (Justice et al., 2006a). Data from the Veterans Aging Cohort Study (VACS) show that among patients followed in eight VA HIV clinics, 96% of patients being treated for HIV received *Corresponding author. Email: breaux.katharineg@med.va.gov AIDS Care Vol. 22, No. 7, July 2010, 886894 ISSN 0954-0121 print/ISSN 1360-0451 online # 2010 Taylor & Francis DOI: 10.1080/09540120903499162 http://www.informaworld.com Downloaded By: [Breaux, Katharine] At: 18:10 21 July 2010