Antiretroviral Guidelines

US DHHS Guidelines with Australian commentary

Poor CD4 Cell Recovery and Persistent Inflammation Despite Viral Suppression

Last Updated: April 8, 2015; Last Reviewed: April 8, 2015

Panel's Recommendations Regarding Poor CD4 Cell Recovery and Persistent Inflammation Despite Viral Suppression

AU comment: Poor CD4 Cell Recovery and Persistent Inflammation Despite Viral Suppression

Panel’s Recommendations

  • Morbidity and mortality from several AIDS and non-AIDS conditions are increased in individuals with HIV despite antiretroviral therapy (ART)-mediated viral suppression, and are predicted by persistently low CD4 T lymphocyte (CD4) cell counts and/or persistent immune activation.
  • ART intensification by adding antiretroviral (ARV) drugs to a suppressive ART regimen does not consistently improve CD4 cell recovery or reduce immune activation and is not recommended (AI).
  • In individuals with viral suppression, switching ARV drug classes does not consistently improve CD4 cell recovery or reduce immune activation and is not recommended (BIII).
  • No interventions designed to increase CD4 cell counts and/or decrease immune activation are recommended at this time (in particular, interleukin-2 is not recommended [AI]) because no intervention has been proven to decrease morbidity or mortality during ART-mediated viral suppression.
  • Monitoring markers of immune activation and inflammation is not recommended because no immunologically targeted intervention has proven to improve the health of individuals with abnormally high biomarker levels, and many markers that predict morbidity and mortality fluctuate widely in individuals (AII).
  • Because there are no proven interventions to improve CD4 cell recovery and/or inflammation, efforts should focus on addressing modifiable risk factors for chronic disease (e.g., encouraging smoking cessation, a healthy diet, and exercise; treating hypertension and hyperlipidemia) (AII).
Rating of Recommendations:  A = Strong; B = Moderate; C = Optional
Rating of Evidence:  I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion