Studies: Delaying Drugs for Some HIV Patients May Be Safe

Symptom-free HIV patients can safely hold off taking AIDS drugs longer than previously thought, according to two new studies. The studies suggest the drugs can still be effective if started when the patient's CD4 count is even lower -- at least 200 -- and even if there are high levels of virus circulating in the blood. They found that for many patients, delaying treatment does no harm.

When antiretrovirals became available in the mid-1990s, many doctors recommended immediate treatment for all HIV patients to keep the virus in check. However, the drugs are expensive, must be switched often to remain effective, and can cause serious side effects, so doctors have sought to delay treatment whenever possible. Recently revised guidelines indicated the drugs could be started when the patient's CD4 count dropped to 350 instead of the previously recommended 500.

In one study, published in today's Journal of the American Medical Association (JAMA Vol. 286; No. 20: P. 2560-2567), researcher Andrew Phillips of Royal Free and the University Medical College Medical School in London and colleagues analyzed data from 3,226 patients treated in European HIV clinics from 1996 to 2000. Patients began treatment with at least three HIV drugs and were followed for an average of more than two years. Eighty-five percent -- 2,741 -- reached undetectable virus levels by 32 weeks. Those who started out with CD4 counts between 200 and 349 fared just as well as those with initial counts of 350 or higher. It took longer for the drugs to suppress the virus in patients who initially had more than 100,000 copies of virus per millimeter of plasma. But they were just as likely as those with lower initial virus levels to reach undetectable levels at 32 weeks.

The second study, also published in today's issue of JAMA (Vol. 286; No. 20; P. 2568-2577), led by researchers Robert Hogg and Dr. Julio Montaner at the University of British Columbia, involved 1,219 HIV patients who started triple-drug treatment between 1996 and 1999. By September 2000, 82 had died of AIDS-related causes. Most deaths were in patients whose initial CD4 counts were less than 200 -- the bulk in those with counts less than 50. Those whose initial counts were around 200 fared just as well as those with higher levels.

Dr. Roger Pomerantz, chief of infectious diseases at Thomas Jefferson University in Philadelphia, said studies will probably change treatment for HIV-infected patients in developed countries, but he cautioned that the recommendations may not be appropriate for some patients. For example, women with relatively low virus levels may develop full-blown AIDS more quickly than men with the same levels.

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