• CD4 + Lymphocyte Level Is Better than HIV-1 Plasma Viral Load in Determining When to Initiate HAART (Slide Session 519)
  Authored by T. R. Sterling, R. E. Chaisson, J. G. Bartlett, and R. D. Moore
  View the original abstract

The U.S. treatment guidelines have been significantly revisited to address when is the best time to recommend beginning treatment with antivirals. While there are many factors that can be used to make this decision, studies have recently focused on this question by comparing the outcomes of those who already have begun treatment. These studies evaluate the impact of initiating treatment at varying CD4 counts and viral loads, and have used the outcomes of preventing AIDS-related illnesses or death to see which groups do well, and if any groups do not do as well.

This study examined the outcomes from the 1,162 patients cared for at the Johns Hopkins Medical Center clinic in Baltimore, Maryland. They monitored the outcomes of any new AIDS-related illness, or death in patients who had started any standard triple antiviral combination. They then compared these rates to patients who had received either no treatment, or those who had used just dual nucleosides for treatment. The major result of this study showed that those who were treated with a potent antiviral combination when their CD4 count was below 200 did better than those who had less potent or no treatment. However, when looking for evidence of the benefits of treatment for those who had started at higher counts, the rates of illness and death were similarly low in those who were treated early when compared to those who delayed treatment as long as their CD4 count was above 200. In other words, the researchers did not see any clear benefit when patients with a CD4 count over 200 started treatment, whereas there was a clear benefit for patients who had begun therapy when their CD4 count was below 200. They also noted that at every viral load level there was similar benefit to treatment.

This study is one of several that have shown the advantages of treatment when it is started for those with a CD4 count below 200. This has led to a widespread sentiment that -- if someone prefers to delay initiating treatment -- starting somewhere around 200 would be the lower end. Those who begin treatment with a CD4 count below 200 have not, in several studies, done as well -- even with antiviral treatment -- as people who had started above 200.

However, it is important to point out that since the risks of illnesses from HIV do not happen at higher counts, it will take many more years to be confident of this analysis for those at higher CD4 levels. It may still be that there are benefits to treatment when started early, as opposed to delaying treatment, but the risks of side effects versus these benefits are more difficult to weigh for those at higher counts. There clearly can be benefits to treating at higher levels for other reasons, but these results are useful in defining a lower limit for those who would prefer to delay treatment.