Slow disease progression and robust therapy-mediated CD4⁺ T-cell recovery are associated with efficient thymopoiesis during HIV-1 infection

In chronic HIV infection, most untreated patients lose naive CD4 ⁺ and CD8⁺ T cells, whereas a minority preserve them despite persistent high viremia. Although antiretroviral therapy (ART)-mediated viral suppression generally results in a rise of naive and total CD4⁺ T cells, certain patients experience very little or no T-cell reconstitution. High peripheral T-cell activation has been linked to poor clinical outcomes, interfering with previous evaluations of thymic function in disease progression and therapy-mediated T-cell recovery. To circumvent this, we used the sj/βTREC ratio, a robust index of thymopoiesis that is independent of peripheral T-cell proliferation, to evaluate the thymic contribution to the preservation and restoration of naive CD4⁺ T cells. We show that the loss of naive and total CD4⁺ T cells is the result of or is exacerbated by a sustained thymic defect, whereas efficient thymopoiesis supports naive and total CD4⁺ T-cell maintenance in slow progressor patients. In ART-treated patients, CD4⁺ T-cell recovery was associated with the normalization of thymopoiesis, whereas the thymic defect persisted in aviremic patients who failed to recover CD4⁺ T-cell counts. Overall, we demonstrate that efficient thymopoiesis is key in the natural maintenance and in therapymediated recovery of naive and total CD4 ⁺ T cells.