Open Access Research article

Predictors of suboptimal CD4 response among women achieving virologic suppression in a randomized antiretroviral treatment trial, Africa

Aida Asmelash1*, Yu Zheng2, Kara Wools Kaloustian6, Douglas Shaffer7, Fred Sawe7, Anthony Ogwu1, Robert Salata5, Judith Currier4, Michael D Hughes2 and Shahin Lockman23

Author Affiliations

1 Botswana Harvard School of Public Health AIDS Initiative Partnership, Gaborone, Botswana

2 Harvard School of Public Health, Boston, MA, USA

3 Brigham and Women’s Hospital, Boston, MA, USA

4 University of California, Los Angeles, LA, USA

5 Case Western Reserve University, Cleveland, OH, USA

6 Indiana University, Indianapolis, USA

7 Walter Reed Project, Kericho, Kenya

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BMC Infectious Diseases 2014, 14:331  doi:10.1186/1471-2334-14-331

Published: 17 June 2014



A subset of HIV-1 infected patients starting highly active antiretroviral treatment (HAART) experience suboptimal CD4 response (SCR) despite virologic suppression. We studied the rate of and risk factors for SCR among women starting HAART in the ACTG A5208 study conducted in 7 African countries. 741 HAART-naive women with screening CD4 count <200 cells/μL were randomized to start HAART with Tenofovir/Emtricitabine plus either Nevirapine or Lopinavir/Ritonavir.


This analysis includes the 625 women who remained on-study through 48 weeks without experiencing protocol-defined virologic failure. We defined SCR as < 100 CD4 cells/μL increase from baseline and absolute CD4 cell count < 350 cells/μL, both at 48 weeks after HAART initiation.


The baseline characteristics for the 625 women prior to HAART initiation were: median age 33 years, screening CD4 count 134 cells/μL, and HIV-1 RNA 5.1 log10 copies/mL; 184 (29%) were WHO Stage 3 or 4.

Seventy one (11%) of these 625 women experienced SCR. Baseline factors independently associated with increased odds of SCR included older age, lower HIV-1 RNA, positive Hepatitis B surface antigen, and site location. At 96 weeks, only 6% of the SCR group had CD4 ≥ 350 cells/μL compared with 67% in the non SCR group.


After starting HAART, 11% of women with virologic suppression through 48 weeks experienced SCR. These patients were also less likely to achieve CD4 ≥ 350 cells/μL by 96 weeks. The underlying causes and long term clinical implications of SCR deserve further investigation.

Trial registration Identifier: NCT00089505

HIV; Antiretroviral therapy; HAART; Immune response; CD4