Better virological outcomes amongst people living with HIV initiating early antiretroviral treatment (CD4 counts ≥ 500 cells/µL) in the HPTN 071 (PopART) trial in South Africa

BACKGROUND: There have been concerns about reduced adherence and HIV virological suppression (VS) amongst clinically well people living with HIV initiating antiretroviral treatment (ART) with high pre-ART CD4 cell counts. We compared virological outcomes by pre-ART CD4 count, where universal ART initiation was provided in the HPTN 071 (PopART) trial in South Africa prior to routine national and international implementation. METHODS: This prospective cohort study included adults initiating ART at facilities providing ART irrespective of CD4 count since January 2014. VS (1000 copies/ml) and viral rebound were compared between participants in strata of baseline CD4 count. RESULTS: The sample included 1901 participants. VS was 94% or greater amongst participants with baseline CD4 count ≥500 cells/µL at all six-monthly intervals to 30 months of ART. The risk of an elevated viral load (≥400 copies/ml) was independently lower amongst participants with baseline CD4 count ≥500 cells/µL (3.3%) compared to those with CD4 count 200-499 cell/µL (9.2%) between months 18-30, adjusted relative risk=0.30 (95% CI: 0.12-0.74, P=0.010). The incidence rate of VF was 7.0, 2.0 and 0.5 per 100 person-years amongst participants with baseline CD4 count <200, 200-499 and ≥500 cells/µL, respectively (P<0.0001). VF was independently lower amongst participants with baseline CD4 count ≥500 cells/µL, adjusted hazard ratio (aHR)=0.23, P=0.045; and three-fold higher amongst those with baseline CD4 count <200 cells/µL, aHR=3.49, P