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Objectives We sought to evaluate associations between CD4 at ART initiation (AI), achieving CD4 &gt;750 cells/mm3 (CD4 &gt;750), long-term immunological recovery and survival. Methods This was a prospective observational cohort study. We analysed data from ART-naive patients seen in 1996–2012 and followed ≥3 years after AI. We used Kaplan–Meier (KM) methods and log-rank tests to compare time to achieving CD4 &gt;750 by CD4 at AI (CD4-AI); and Cox regression models and generalized estimating equations to identify factors associated with achieving CD4 &gt;750 and mortality risk. Results Of 1327 patients, followed for a median of 7.9 years, &gt;85% received ART for ≥75% of follow-up time; 64 died. KM estimates evaluating likelihood of CD4 &gt;750 during 5 years of follow-up, stratified by CD4-AI  750 [adjusted HR (aHR) = 4.77]. Blacks were less likely than whites to achieve CD4 &gt;750 (33% versus 49%, aHR = 0.77). Mortality rates decreased with increasing CD4-AI (P = 0.004 across CD4 strata for AIDS causes and P = 0.009 for non-AIDS death causes). Among decedents with CD4-AI ≥50, 56% of deaths were due to non-AIDS causes. Conclusions Higher CD4-AI resulted in greater long-term CD4 gains, likelihood of achieving CD4 &gt;750, longer survival and decreased mortality regardless of cause. Over 80% of persons with CD4-AI ≥350 achieved CD4 &gt;750 by 4 years while 75% of persons with CD4-AI &lt;200 did not. These data confirm the hazards of delayed AI and support early AI.

CD4 cell count at initiation of ART, long-term likelihood of achieving CD4 >750 cells/mm3 and mortality risk