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Earlier treatment of patients with HIV may reduce mortality risk
Initiation of treatment at higher CD4 cell counts decreased mortality by 70%.
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WASHINGTON — Initiation of antiretroviral therapy when CD4 cell counts are between 351 cells/mm3 and 500 cells/mm3 may reduce mortality risk in patients with HIV, according to findings presented at the 2008 ICAAC/IDSA Meeting, held here recently.
Current guidelines stipulate that treatment should begin when cell counts reach 350 cells/mm3.
Mari Kitahata, MD, and colleagues from the University of Washington in Seattle conducted the study. They analyzed results of 22 prospective cohorts in the United States and Canada. Data from 8,374 patients were available. The study years were 1996 to 2006.
Eligible patients had baseline CD4 cell counts between 351 cells/mm3 and 500 cells/mm3. There were 2,473 patients who began ART when cell counts were between 351 cells/mm3 and 500 cells/mm3. There were 5,901 patients who deferred treatment, including those who started treatment when their CD4 cell count went below 350 cells/mm3, as per clinical guidelines.
Patients who opted for early treatment had a 70% lower risk for early death than those who waited. – by Rob Volansky
The controversy about when to start ART has heated up as treatments have become more effective. The guidelines are moving in the direction of earlier initiation. This study’s results are important because they demonstrate a survival advantage to starting ART even when the CD4 count is still relatively high. The results reinforce the clinical sense that a lot of physicians have about how we should be approaching HIV therapy. There is damage being done to people with HIV even while the CD4 count is still high, and these results give us another reason to start treating patients earlier.
This paper is triggering a lot of speculation that perhaps it is time to start treating essentially all people with HIV. It has come at a time when the field is ready for the kind of observations that result in a fairly substantial rethinking of some accepted positions.
However, the matter is not settled. There are people who point out, and rightly so, that there is a difference between a retrospective cohort analysis and a prospective clinical trial result. But many feel that it is unlikely that a clinical trial would be successful in addressing this. It would have to be large, and it would take a long time. Also, it would involve treating people in parts of the world where collection of data would be somewhat concerning. It is not difficult to design such a trial, but it is difficult to fund it and conduct it. However, even though a trial conducted to determine the effectiveness of earlier treatment beyond a shadow of a doubt would be costly, I think there also is a cost associated with waiting to make this decision.
There has been vigorous debate about this issue. Some feel we have enough evidence to start initiating therapy earlier. Many feel that we should not use the resources that are required for a clinical trial when we could be treating patients right away. Others say that we need to conduct a clinical trial.
One other growing argument is that treating large numbers of people will decrease the frequency of transmission. There are a few possible reasons for this. Either a person who is infected and being treated knows the risks and may be less likely to engage in risky behavior, or the medication itself is likely to decrease risk for transmission.
In any case, with all factors considered, there is no doubt that this debate is not yet settled.
– Paul Volberding, MD
Infectious Disease News editorial advisory board member
For more information:
- Kitahata M. Initiating rather than deferring HAART at a CD4 count between 351-500 cells/mm3 is associated with improved survival. Presented at: the 2008 ICAAC/IDSA Meeting; Oct 25-28, 2008; Washington.