Disease progression, adherence, and response to protease inhibitor therapyfor HIV infection in an urban Veterans Affairs Medical Center

Indinavir therapy has demonstrated promise in the treatment of HIV-I infect ion in clinical trials; however, its efficacy in a U.S. Veterans Affairs Me dical Center, where access to therapy is generally unimpeded, is unknown. A review of the Miami cohort was conducted for the year beginning May 1996 t o evaluate response to indinavir plus two nucleoside analogues. Of 483 HIV- 1-positive patients (97% male; mean age, 46.7 +/- 9.7 years), 266 were offe red indinavir based on their having CD4 counts <200 cells/mu l or viral loa ds >10,000 copies/ml. Of these patients, 36% were adherent and experienced significant reductions in viral loads (-93,325 +/- 147,911 copies/ml) and e levations in CD4(+) (111 +/- 103 cells/mu l) and CD8(+) (225 +/- 338 cells/ mu l) T cell counts. Adherent patients with baseline CD4 counts <100 cells/ mu l were 4.5 times more likely to have follow-up viral loads >10,000 copie s/ml than those with CD4 >200 cells/mu l. Adherent patients with CD4 counts <100 cells/mu l did not show evidence of immune "exhaustion" because they were equal to those with CD4 counts >200 cells/mu l in their capacity to re plenish CD4 cells. Nonadherence to the regimen resulted in loss of therapeu tic benefit and suggested that strategies to enhance adherence may become a n essential component of treatment.