2010 Guidelines for Antiretroviral Treatment of HIV From the International AIDS Society–USA Panel—Reply

In Reply: Dr Bucher and colleagues present information from the CASCADE collaboration relevant to the recommendations of the antiretroviral guidelines panel of the International AIDS Society–USA panel to initiate ART in the setting of CD4 cell count decline greater than 100/μL per year. The panel's recommendation regarding CD4 cell decline was informed by natural history data from the Multicenter AIDS Cohort Study (MACS).¹ Seroconverters in that cohort demonstrated a mean rate of CD4 cell count decline of 109/μL over the first 3 years following seroconversion. This analysis found CD4 slope to be significantly associated with time to clinical AIDS. To exclude potent ART use, only visits prior to 1990 were included. Other studies have confirmed the prognostic value of CD4 slope; however, they also have confirmed its high variability and relatively weak prognostic value relative to pretreatment plasma HIV RNA or CD4 cell count.^2- 3