University of California, San Diego, USA.
AIDS. 2011 Sep 10;25(14):1747-51. doi: 10.1097/QAD.0b013e32834a40cd.
Despite immune recovery in individuals on combination antiretroviral therapy (CART), the frequency of HIV-associated neurocognitive disorders (HANDs) remains high. Immune recovery is typically achieved after initiation of ART from the nadir, or the lowest historical CD4. The present study evaluated the probability of neuropsychological impairment (NPI) and HAND as a function of CD4 nadir in an HIV-positive cohort.
One thousand five hundred and twenty-five HIV-positive participants enrolled in CNS HIV Antiretroviral Therapy Effects Research, a multisite, observational study that completed comprehensive neurobehavioral and neuromedical evaluations, including a neurocognitive test battery covering seven cognitive domains. Among impaired individuals, HAND was diagnosed if NPI could not be attributed to comorbidities. CD4 nadir was obtained by self-report or observation. Potential modifiers of the relationship between CD4 nadir and HAND, including demographic and HIV disease characteristics, were assessed in univariate and multivariate analyses.
The median CD4 nadir (cells/μl) was 172, and 52% had NPI. Among impaired participants, 603 (75%) had HAND. Higher CD4 nadirs were associated with lower odds of NPI such that for every 5-unit increase in square-root CD4 nadir, the odds of NPI were reduced by 10%. In 589 virally suppressed participants on ART, higher CD4 nadir was associated with lower odds of NPI after adjusting for demographic and clinical factors.
As the risk of NPI was lowest in patients whose CD4 cell count was never allowed to fall to low levels before CART initiation, our findings suggest that initiation of CART as early as possible might reduce the risk of developing HAND, the most common source of NPI among HIV-infected individuals.
尽管接受联合抗逆转录病毒疗法（CART）的个体的免疫功能得到恢复，但仍有很高比例的 HIV 相关神经认知障碍（HAND）。通常，在开始 ART 治疗后，免疫功能会从 CD4 最低点（nadir）或历史最低 CD4 水平恢复。本研究评估了 HIV 阳性队列中 CD4 最低点与神经心理损伤（NPI）和 HAND 的关系。
1525 名 HIV 阳性参与者入组 CNS HIV 抗逆转录病毒治疗效果研究，这是一项多中心、观察性研究，参与者完成了全面的神经行为和神经医学评估，包括涵盖七个认知域的神经认知测试组合。在受损个体中，如果无法归因于合并症，则诊断为 HAND。通过自我报告或观察获得 CD4 最低点。在单变量和多变量分析中评估了 CD4 最低点和 HAND 之间关系的潜在修饰因子，包括人口统计学和 HIV 疾病特征。
中位 CD4 最低点（细胞/μl）为 172，52%的人存在 NPI。在受损参与者中，有 603 人（75%）患有 HAND。CD4 最低点越高，NPI 的可能性越低，即 CD4 平方根每增加 5 个单位，NPI 的可能性降低 10%。在 589 名接受 ART 治疗且病毒抑制的参与者中，在调整人口统计学和临床因素后，CD4 最低点越高，NPI 的可能性越低。
由于在开始 CART 治疗前，患者的 CD4 细胞计数从未降至低水平时，NPI 的风险最低，我们的研究结果表明，尽早开始 CART 治疗可能会降低 HAND 的风险，HAND 是 HIV 感染者中最常见的 NPI 来源。
