Jan 4, 2005
After reading a host of materials on treatment initiation for those starting their first line treatment, I can't help but wonder if the current guidelines are not factoring in the lower side effect profile for the so called 'gold standard' meds.
I keep having a reoccuring thought: at the end of the day this virus is deadly and controlling it at an earlier stage may preserve the immune function and allow for greater flexibility in the future as new classes of drugs roll out. In fact, I believe there was a recent study that indicated that starting therapy above the 350 tcell threshold resulted in fewer side effects and increased treatment effect. I realize the best drugs today are not free of side effects but why not give it a try first and if there is a bad reaction there is always the option to stop and re-evaluate since treatment was started at a higher t-cell level.
I'd appreciate your thoughts as an experienced clinician in this area.
Response from Dr. Pierone
I think that early treatment of HIV infection may be where we are headed based on several factors.
The first consideration is that several STI studies have shown that the best predictor of successfully stopping therapy is having higher CD4 cells before initiating therapy. The implication is that by avoiding immune depletion we might be better able to periodically stop therapy in the future. So starting sooner than 350 makes some sense based on these STI studies, here is a link to a summary of one such trial called BASTA.
Another issue is that, in fact, current first-line therapy is more effective and better tolerated than older regimens and this tips the balance towards earlier treatment. There are also studies that show it is easier to keep the virus at bay and control viral replication when CD4 counts are higher and the viral load levels are a bit lower. You touched upon another point - the decision to initiate antiretroviral therapy is not an irrevocable contract. Some people begin therapy and never blink an eye have no side effects, and quickly see an undetectable viral load. Others have myriad adverse reactions and stop HAART because of a significant reduction in life quality. This latter scenario occurs much less often now because of the availability of better antiretroviral medications.
The movement back towards earlier treatment is mainly held in check by the real concerns of non-adherence, drug resistance, and cumulative antiretroviral toxicity. Hopefully the results of ongoing studies like SMART will help us better understand the risks and benefits of earlier HIV treatment. Thanks for posting.
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