Study Supports Earlier Antiretroviral Treatment, Researchers Call for Amended Recommendations

In in the journal Lancet on Thursday, researchers published findings that they say support calls for starting antiretroviral treatment earlier than some current recommendations, AFP/Yahoo! News reports. According to AFP/Yahoo! News, there are no universal guidelines for when HIV-positive people should begin highly active antiretroviral therapy, but a common recommendation is to begin the treatment when CD4+ T cell counts decline below 200 to 250. Some researchers argue that this recommendation is too low and that more lives could be saved if the treatment was started sooner, according to AFP/Yahoo! News.

For the study, Jonathan Sterne of the University of Bristol and colleagues compared previous studies that followed more than 45,000 HIV-positive people in Europe and North America (AFP/Yahoo! News, 4/8). The data for the study included 21,247 HIV-positive people followed from 1989 to 1995 -- before antiretroviral treatments were developed -- and 24,444 HIV-positive people since 1998, according to Reuters. All of the participants had not progressed to AIDS and had CD4 cell counts of less than 550. In addition, none of the participants reported a history of injection drug use (Reuters, 4/8). According to the study, people who began antiretroviral treatment when their CD4 counts were less than 350 were 28% more likely to develop AIDS or die prematurely than those who began treatment with CD4 counts of 351 to 450. The study also said that the findings support earlier HIV treatment initiation, particularly as new antiretrovirals have fewer side effects than earlier treatments. The study said, "In view of diminished concerns about toxic effects and resistance, our results suggest that 350 cells per microliter should be the minimum threshold at which antiretroviral therapy is started" (AFP/Yahoo! News, 4/8). According to the researchers, the beneficial effects of earlier treatment initiation were especially significant during the first two years of treatment.

The researchers also conducted a repeat analysis among 4,605 HIV-positive injection drug users, which showed similar results. The authors said the results "should be applicable to many patients starting or considering starting combination therapy in developed countries." In a related commentary also published in Lancet, Robin Wood and Stephen Lawn -- both of the University of Cape Town in South Africa -- said that the "question of when to start [antiretroviral treatment] might have more than one right answer." Wood and Lawn noted that the risk-to-benefit ratio of early antiretroviral treatment initiation remains uncertain in developed countries, adding that in low-income settings, the prevalence of AIDS and AIDS-related deaths are typically higher both before and after starting treatment. In the commentary, the authors suggested randomized trials that take into consideration such issues in both types of settings (Reuters, 4/8).