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Starting HAART Earlier
Aug 4, 2006

Hi Dr. Henry:

I was wondering if you saw this:

HIV Can Replicate in Intestinal Lining Even After HAART Reduces Viral Load, Study Says August 1, 2006

HIV can replicate and suppress the immune system in the intestinal lining, even after blood tests show that highly active antiretroviral therapy is reducing viral loads, according to a study published in the August issue of the Journal of Virology, London's Times reports (Lister, Times, 7/29). Moraima Guadalupe of the University of California-Davis Health System's Department of Medical Microbiology and Immunology and colleagues took blood and intestinal samples of 10 HIV-positive people before and after three years of treatment with HAART (Reuters, 7/29). Three of the people began HAART within four to six weeks of contracting HIV, and seven began treatment at least one year after becoming HIV-positive, BBC News reports (BBC News, 7/29). According to the study, samples from people who started HAART earlier showed less inflammation and greater revival of the mucosal immune system in the gut than the samples of other study participants (CBC News, 7/28). "We found a substantial delay in the time that it takes to restore the gut mucosal immune system in those with chronic infections," Satya Dandekar, chair of the at the UC Davis Health System microbiology and immunology department and senior author of the study, said, adding, "In these patients the gut is acting as a viral reservoir that keeps us from ridding patients of the virus" (Xinhuanet, 7/29). "If we are able to restore the gut's immune response, the patient will be more likely to clear the virus," Thomas Prindiville, a UC Davis professor and a study co-author, said. The study recommends gut biopsies for patients taking HAART and says that earlier onset of HAART and use of anti-inflammatory drugs could help revive immune function in the "gut-associated lymphoid issue," which accounts for about 70% of a person's immune system, the Times reports (Times, 7/29).

Is this a strong argument for starting treatment earlier? Does it add to what the SMART study showed..ie. it's more dangerous than we thought to be off of treatment?? I'm not on treatment yet (550 t cells) but I think the argument seems to be going to starting earlier...what do you think?

Response from Dr. Henry

I saw that. The treatment pendulum does seem to be swinging back to earlier initiation of therapy when there are resources to maintain treatment once started and with many of the newer more potent regimens. That being said, starting treatment is a big deal with data showing that stopping treatment once started is not wise for many patients and treatment may be life long (many decades). For most patients with a CD4 count > 500 the risk for an AIDS-related event in the next 3 years is low so the clinical benefit of starting therapy very early is hard to demonstrate. Careful monitoring and working on other health issues while awaiting HIV treatment is a strategy that works well for most patients that I see with CD4 counts > 350.



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