HIV with high CD4 count: early ART reduces risk for severe bacterial infections

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  • Immediate antiretroviral therapy (ART) reduces risk for a broad spectrum of severe bacterial infections in HIV-infected patients, and appears to be mediated partly by increases in CD4 cell count, but not neutrophils.

Why this matters

  • Effect of early ART on bacterial infections is important because these events are common in HIV-infected patients.

Key results

  • After median follow-up of 2.8 y, 120 of 4685 HIV-positive patients had severe bacterial infections (immediate-initiation group n=34, deferred-initiation group n=86).
  • Immediate vs deferred ART was associated with reduced risk for severe bacterial infection (HR, 0.39; P<.0001).
  • Average neutrophil and CD4 cell counts were 321.4 cells per μL and 194.2 cells per μL higher, respectively, in immediate- vs deferred-initiation groups (P<.0001).
  • On univariable analysis, higher time-updated CD4 cell count, but not neutrophil count was associated with reduced risk for severe bacterial infection.
  • After adjustment for time-updated CD4 cell count in multivariable models, HR for immediate-initiation group moved toward 1 (HR, 0.84; P=.52).

Study design

  • Preplanned secondary analysis of START to determine effects of immediate ART on all severe bacterial infections.
  • Funding: Various international government sources, including National Institutes of Health.


  • Bacterial pneumonia and tuberculosis reported as main endpoints; few events limits study power.