HIV/AIDS
New Research: Giving HIV Medications Sooner Greatly Improves Outcomes
By L. K. Regan
Published Nov 25, 2008
Published Nov 25, 2008
The medical community is wrestling with the fallout from a breakthrough study, presented late last month at the joint meeting of the American Society of Microbiology and the Infectious Diseases Society of America, suggesting that the current method of administering medication for HIV is not only not ideal—it may be compromising patients' long-term health.
The study was the work of a team of researchers from the University of Washington in Seattle and American and Canadian colleagues, who examined the records of nearly 8,374 HIV patients held in International Epidemiology Databases to Evaluate AIDS, a global network of HIV clinics from 1996 to 2006. Specifically, they were looking for the impact of starting retroviral medications sooner rather than later. Their finding: that delaying medication until the immune system was damaged nearly doubled a patient's risk of dying in the next few years.
For the last decade, HIV has become largely a manageable illness. Though the quest for a vaccine for the virus has proven frustratingly difficult, treatment is available (for those who can afford it) and effective. Yet until now, doctors have had little certainty about when to begin treating the illness with HAART, or "highly active antiretroviral therapy". And in general, they have tended to delay such treatments until they see signs of damage to the patient's immune system from the virus. That has meant counting the patient's CD4 T-cells, a type of immune cell, and beginning treatment at the point that the number of these cells falls below 350 per milliliter of blood (in a healthy person, the number would be closer to 800).
There have been many reasons for this protocol. In its original form, HAART was a difficult therapy to maintain. It typically has involved taking many pills each day. Side effects have also been crippling for many patients. Patients have to be very vigilant, as missing doses will lead to drug resistance and the treatment will cease to be effective, contrary to previously-prescribed "drug holidays", which now are viewed as profoundly dangerous. All of these factors led doctors to advise that people delay the treatment as long as realistically possible. "There was this thinking, maybe the drugs were worse than the disease. If you could wait as long as you possibly could wait, you would have fewer side effects," said Dr. Robert Schooley, chief of infectious diseases at the University of California, San Diego.
The current study suggests that this is not an effective approach. Researchers found that initiating treatment immediately led to a nearly 70 percent improvement in survival. Specifically, the 30 percent of participants in the higher survival group began therapy when their CD4 counts were between 350 and 500, rather than allowing those levels to sink below 350, as would be the usual standard. This confirms and expands upon the conclusions of two other recent studies that found that people who began medication when their CD4 counts were above 350 were more likely to return their counts to normal than those who delayed treatment until the CD4 counts fell below 350. "The data are rather compelling that the risk of death appears to be higher if you wait than if you treat," said Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, which helped fund the study.
Drug therapies for HIV have been consistently improving in recent years. Newer therapies have fewer side effects, and may only require taking one or two pills a day. As a result, the emphasis on early diagnosis could increasingly come to focus on reducing infection. Yet this study promises both to force the medical community to rethink its protocols for treating HIV, and to put pressure on public health campaigns aimed at diagnosis. Early diagnosis, it turns out, may well have serious implications not only for preventing the spread of the disease, but as part of an effective individual treatment approach. And in the near term, the study may mean that hundreds of thousands of HIV+ persons who are not currently on medication will be encouraged to start.
The study was the work of a team of researchers from the University of Washington in Seattle and American and Canadian colleagues, who examined the records of nearly 8,374 HIV patients held in International Epidemiology Databases to Evaluate AIDS, a global network of HIV clinics from 1996 to 2006. Specifically, they were looking for the impact of starting retroviral medications sooner rather than later. Their finding: that delaying medication until the immune system was damaged nearly doubled a patient's risk of dying in the next few years.
For the last decade, HIV has become largely a manageable illness. Though the quest for a vaccine for the virus has proven frustratingly difficult, treatment is available (for those who can afford it) and effective. Yet until now, doctors have had little certainty about when to begin treating the illness with HAART, or "highly active antiretroviral therapy". And in general, they have tended to delay such treatments until they see signs of damage to the patient's immune system from the virus. That has meant counting the patient's CD4 T-cells, a type of immune cell, and beginning treatment at the point that the number of these cells falls below 350 per milliliter of blood (in a healthy person, the number would be closer to 800).
There have been many reasons for this protocol. In its original form, HAART was a difficult therapy to maintain. It typically has involved taking many pills each day. Side effects have also been crippling for many patients. Patients have to be very vigilant, as missing doses will lead to drug resistance and the treatment will cease to be effective, contrary to previously-prescribed "drug holidays", which now are viewed as profoundly dangerous. All of these factors led doctors to advise that people delay the treatment as long as realistically possible. "There was this thinking, maybe the drugs were worse than the disease. If you could wait as long as you possibly could wait, you would have fewer side effects," said Dr. Robert Schooley, chief of infectious diseases at the University of California, San Diego.
The current study suggests that this is not an effective approach. Researchers found that initiating treatment immediately led to a nearly 70 percent improvement in survival. Specifically, the 30 percent of participants in the higher survival group began therapy when their CD4 counts were between 350 and 500, rather than allowing those levels to sink below 350, as would be the usual standard. This confirms and expands upon the conclusions of two other recent studies that found that people who began medication when their CD4 counts were above 350 were more likely to return their counts to normal than those who delayed treatment until the CD4 counts fell below 350. "The data are rather compelling that the risk of death appears to be higher if you wait than if you treat," said Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, which helped fund the study.
Drug therapies for HIV have been consistently improving in recent years. Newer therapies have fewer side effects, and may only require taking one or two pills a day. As a result, the emphasis on early diagnosis could increasingly come to focus on reducing infection. Yet this study promises both to force the medical community to rethink its protocols for treating HIV, and to put pressure on public health campaigns aimed at diagnosis. Early diagnosis, it turns out, may well have serious implications not only for preventing the spread of the disease, but as part of an effective individual treatment approach. And in the near term, the study may mean that hundreds of thousands of HIV+ persons who are not currently on medication will be encouraged to start.
eldela28 wrote:
I'm very frustrated, because of the negative the new Rx (Truvada) I started taking (together with Reyataz) has done to my liver. My enzyme levels have increased in 5 months. Before Truvada, I was taking Combivir and Reyataz. Following my Dr's advice, I switched to Truvada, on the basis that Combivir has higher amt. of AZT than Truvada. When I was combining both, my enzyme level was not high and my liver healthier. I am so confused (and frustrated) since I don't know what to do. Guess can only wait to see what happens in the next 2-3 mos. and see if I should discontinue Truvada or not.
Any suggestions from anyone?
May 06 2:01 AM
MACGUYSEA wrote:
As someone who has been positive for the past nearly 7 years, it is sad to hear of many of the attitudes coming from within the gay community. It shows a severe lack of education and often times, unfounded fear. What some people fail to see are the PEOPLE behind this illness. I for one do not let it dictate who I am or what I'm capable of. I live with it day in, day out. This coming February 5th will be officially 7 years; I happen to turn 39 three days later... Do not let HIV come in between you and potentially a great partner in life. You might be amazed.
Dec 02 12:03 AM
workinitup wrote:
It is not your CD4 count that determines your HIV status, it is the presence of HIV (virus) in your body. Basic HIV testing actually tests for the presence of antibodies your body produces to fight the virus. The virus can be measured with further blood testing to determine viral count within a cubic millimeter of blood, if the count is below 50 per cubic mm the virus is considered undetecable. That does NOT mean that a person who's viral count is considered undetectable cannot pass the virus from one person to another. Tracking CD4 counts is important to be aware of the condition of a persons immune system. It is thought by my doctor that if one's immune system is allowed to be hit hard enough by the virus before treating it, one's immune system could possibly never recover. I'm glad that I decided to start therapy right away, and I consider myself lucky that I did not have serious reactions to my meds. I did have to alter my meds but found a combination that works for me.
Dec 01 7:34 PM
RyanRebornG0y wrote:
HIV KILLS! It's sad how they try to pass it off as something you can manage to live with... just sad. =/
Nov 30 8:10 AM
skipskip wrote:
At what cd4t cell count does one have HIV - anything below 800 ?
At what cell count can one infect others ? skipskip
Nov 27 8:59 AM
bradsmith wrote:
This is fascinating...yet truly frustrating! In the 25+ years that I've been infected, I've watched the recommended therapy veer from extreme to the other...remember HAART (Highly Active Anti-Retro-Viral Treatment)? That theory was hit HIV hard and fast... That disappeared about 5 years ago, to be followed by, wait as long as possible before starting treatment; let the body's natural defenses work as long as possible. And now this. Truly it is amazing how much more we understand about HIV...and still, how little! And hopefully a note of caution to those who feel they have nothing to fear from HIV...
Nov 26 3:13 AM