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Early initiation of ART may significantly improve HIV survival rates

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Survival rates may be significantly higher for patients with HIV who initiate antiretroviral therapy early in the course of disease compared with patients who defer treatment, according to new results from a multicenter analysis of North American patients with HIV that was recently published in The New England Journal of Medicine.

Researchers reviewed data from 17,517 asymptomatic, antiretroviral therapy (ART)-naive patients with HIV in the United States and Canada during 1996 to 2005. They stratified patients by CD4 cell counts: those with cell counts between 351 cells/mm³ and 500 cells/mm³, and those with cell counts greater than 500 cells/mm³. They then divided these two groups into cohorts of patients who initiated treatment when CD4 cell counts were above the thresholds of interest and patients who deferred treatment until cell counts decreased to levels below the thresholds.

The aim of the study was to compare the RR for death among patients who initiated therapy early with that of patients who deferred therapy. The researchers conducted parallel analyses.

In the first analysis, there were 8,362 patients: 2,084 (25%) of whom were in the early treatment group and 6,278 (75%) of whom were in the deferred treatment group. The RR for death was 1.69 (95% CI, 1.26-2.26) in the deferred therapy group.

The first analysis also demonstrated that older age was associated with an increased risk for death. There was a RR of 1.68 for each 10-year increment (95% CI, 1.48-1.91). There was a RR for death of 1.64 (95% CI, 1.10-2.44) for patients with a history of injection drug use in this group. Patients with a history of hepatitis C virus (HCV) had a RR for death of 1.85 (95% CI, 1.07-3.23).

The second analysis involved 9,155 patients, and 2,220 (24%) those patients initiated therapy early and 6,935 (76%) of patients deferred. The RR for death in the deferred therapy group was 1.94 (95% CI, 1.37-2.79).

In an accompanying editorial, Nathan Ford, DHA, et al, examined the approaches to ART in African patients. Ford and his colleagues wrote that the current approach to ART in Africa is flawed for a number of reasons, not the least of which is that the focus of health care interventions in the developing world has begun to shift away from HIV/AIDS. They also wrote that too few people in Africa are receiving treatment, and that the policy of waiting until patients are visibly ill or reach CD4 cell counts less than 200 cells/mm³ contributes to an ongoing crisis. Furthermore, the use of ineffective or toxic drugs may be responsible for other health complications among patients with HIV/AIDS in Africa.

Though switching drugs and initiating treatment earlier may require investment from the international community at the outset, the health benefits in patients may lead to reduced long-term costs. – by Rob Volansky

Kitahata M. N Engl J Med. 2009;360:1815-1826.

Ford N. N Engl J Med. 2009;360:1808-1810.