We confirmed this by showing that CD4 cell count trajectories among patients who subsequently died were markedly lower than

for other patients (data available on request). Although random-effects models account for dropout, estimates from these models may also be biased if the dropout mechanism is not predicted by observed CD4 measurements. One solution is to jointly model the dropout mechanism and CD4 cell counts, GS-1101 datasheet although these types of model can be highly sensitive to model misspecification [27,28]. Our analysis was restricted to the subset of patients who had eligible pre- and post-cART CD4 cell counts, and viral load measurements within 6 months of each CD4 measurement. CCI-779 solubility dmso Over the study period, CD4 cell count and HIV-1 RNA were generally measured at least every 3 months. Although this restriction resulted in exclusion of 3682 patients, the only difference in the characteristics of patients who were and were not excluded was a longer median follow-up time among those excluded. As this was an observational study, we were unable to rule out

unmeasured confounding. Individuals who choose to start cART at high CD4 cell counts often have very different characteristics to those who delay cART. Patients starting cART at very low counts were more likely to be female, of Black African ethnicity, and heterosexual, consistent with findings in the UK that individuals with these characteristics are more likely to be diagnosed with HIV at late stages of disease. There may be many other characteristics, particularly in terms of participant attitudes, beliefs and health-seeking behaviours [29], that differ among patients starting cART with different CD4 cell counts, many of which cannot be captured in a cohort such as ours. In summary, CD4 cell counts continued to increase up to 8 years after initiation of cART in patients who maintained virological

suppression, Silibinin although differences according to baseline CD4 cell count were maintained. Periods of virological failure were associated with reductions in subsequent geometric mean CD4 cell counts. The impact of virological failure was greater if the viral load was higher, but declined with time since last failure. Adverse effects of treatment interruption on subsequent CD4 cell counts appeared to be largely mediated through virological failure. These results support hopes that, given continuing virological suppression, many patients will ultimately be able to attain normal or near-normal CD4 cell counts regardless of their baseline CD4 cell count. The authors would like to thank all the clinicians, data managers and research nurses in participating clinical centres who have assisted with the provision of data for this project. Funding was provided by UK Medical Research Council (grants G0600337 and G0000199) and R.H.