Drug Regimen for HIV Could Be Safely Delayed, Two Studies Show

People with HIV might be able to delay triple antiretroviral therapy longer than previously thought without hurting themselves, according to two studies presented Tuesday at the 14th International AIDS Conference. Starting treatment when the CD4 cell count has dropped to a level close to 200 might be only marginally riskier than starting when the count is over 350. Waiting that long will save the average patient a year and a half of taking drugs.

When to start treatment is one of the most difficult medical decisions HIV-infected people face. The pills can be life-sustaining, but they have to be taken regularly, can change one's physical appearance, are expensive and are occasionally dangerous. When triple drug therapy began in 1996, doctors recommended early, aggressive treatment. Early treatment was later abandoned as it became clear that the drugs often work well in relatively advanced cases but can never cure the infection, even when used early. The federal government's current recommendation is to start treatment when the CD4 count falls below 350.

In one study, Alvaro Munoz of Johns Hopkins University's Bloomberg School of Public Health compared the experience of people who started triple therapy when their CD4 counts were below 200 to those who began triple therapy with counts between 201 and 350, and between 351 and 500. Normal CD4 count is about 600 to 800.

Munoz and colleagues measured the time people stayed healthy and free of AIDS after starting therapy, compensating for the fact that people who started with high CD4 counts were likelier to have longer AIDS-free survival than those who started with lower counts because it takes time for a count to fall. Their results showed that it was detrimental to defer treatment until the CD4 count was below 200. But there was almost no difference in outcome between people starting treatment when the CD4 count was 201-350 and those starting it at a count of 351-500. A study presented by Genevieve Chene of Bordeaux, France, found a similar outcome. She and her colleagues examined the experience of about 12,600 people taking antiretrovirals, comparing when they started treatment, how they acquired the infection, and other variables.

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