News / Africa

Starting AIDS Treatment Much Earlier May Mean Longer, Healthier life

Multimedia

Audio
Joe DeCapua

Over the years, there’s been debate over when to start HIV-positive patients on anti-retroviral drugs, or ARVs.  At first the standard practice was to wait until a person’s immune system had nearly collapsed.  But a growing body of research shows there may be many benefits to starting treatment much earlier.

Measuring the number of CD4 immune cells is a major determining factor on when to begin drug treatment.  It was the norm to give ARVs to people who either had full-blown AIDS or had CD4 counts below 200.

Now it’s generally accepted that anti-retrovirals should be given when the count drops below 350.  But there’s debate over whether to start treatment even earlier than that.

Dr. Roy Gulick, Weill-Cornell Medical Center
Dr. Roy Gulick, Weill-Cornell Medical Center

The subject was discussed at the recent OPMAN XVIII, the Optimal Management of HIV Disease Conference.  

Dr. Roy Gulick, professor of medicine at the Weill-Cornell Medical Center in New York City, says, “It’s ironic that 23 years now into anti-retroviral therapy we are still asking a very basic question.  And that is, when should we start?”

Pros and cons

Gulick outlines a few reasons for starting anti-retroviral treatment early.

“We know that our treatment decreases viral load levels and thus the emergence of (drug) resistance and also increases CD4 cell counts and general immune function.  We have published data to show that our best regimens can suppress viral load levels for up to seven years or longer,” he says

What’s more, he says, “Treatment likely reduces transmission in the community.  That is, treatment can be prevention.”

Starting earlier may also be more cost effective.

Some of the reasons for delaying treatment have included the inconvenience and toxicity of anti-retrovirals and their long-term side effects.  

“On balance, up until recently, we have elected to wait to start.  But there is a lot of data, newer data, to suggest that the balance of this question is likely shifting,” he says.

There had been general agreement that ARV treatment should be started for anyone with AIDS, symptomatic HIV disease or CD4 counts less than 200.

But there’s now agreement on a second group with a higher count.

“That is asymptomatic with CD4s between 200 and 350.  The developed country guidelines all changed to a firm yes in 2008.  And the newest guidelines to now suggest this are the WHO (World Health Organization) ’09 guidelines, which now say, yes, we should be treating anyone with HIV disease, regardless of symptoms, with a CD4 (count) less than 350,” he says.

A study in Haiti helped persuade the World Health Organization to recommend starting treatment earlier.  Fewer deaths and infections were found in those who received ARVs sooner.  Besides a drop in mortality, earlier treatment resulted in fewer tuberculosis cases among patients.

“This was the data that caught the eye of the WHO and really the world and said that we should be starting earlier throughout the world,” he says.

Gulick says the shift to earlier treatment is also due, in part, to “easier, less toxic and more potent therapy.”

He says, “So we go from handfuls of 20 plus pills taken three times daily to as few as one pill once a day.”

Starting AIDS Treatment Much Earlier May Mean Longer, Healthier life
Starting AIDS Treatment Much Earlier May Mean Longer, Healthier life

There are also the findings of many cohort studies to support earlier treatment. The findings are based on thousands of HIV patients, whose progress was followed in clinics.

In 2002, in one study, no difference was seen in those receiving treatment when their CD4 counts were between 200 and 350 and those who started treatment when their counts were over 350.  At least that was the case after comparing the two groups over a three-year period.

“Although there’s no difference at three years,” he says, “at five years, this now reaches statistical significance.  So, there was a benefit to starting earlier in this cohort study.  And it took over three years, more like five years, to convincingly show the clinical benefit here.”

Proof enough?

The professor of medicine asks if the results appear good for those receiving treatment at this stage, why not start even earlier? In other words, a CD4 count above 350.  Some cohort studies seem to support this, but Gulick says those studies are not always enough to go on.

“Well, what’s the problem with all the data I’ve shown you so far?  And that is it’s not randomized clinical trial data.  These are cohort patients.  That is, general patients followed in clinics,” he says.

And these patients may be different.

“It’s safe to say that patients who elect to start ART (anti-retroviral therapy) with high CD4s may not be the same as patients who defer ART with the same high CD4s,” he says.

Those who choose to start treatment sooner may have better health habits.  

“They may use seatbelts more.  They may exercise more.  There may be other confounding reasons why they have general better health than the group who elects to defer.  So we have to take all this cohort data somewhat with a grain of salt,” Gulick says.

And some cohort studies found starting treatment at a much higher 450 to 550 CD4 count showed no significant benefits.

To try to settle the issue, a formal clinical study – the Start study – is now underway.  It’s enrolled patients with CD4 counts higher than 500.  The study could finally determine whether it’s more beneficial to start treatment immediately or wait until CD4s drop below 350, the current standard.  However, the results may not be known for six years.  

Some say the there’s enough data from the cohort studies to not wait for the Start study results.  

You May Like

Scotland Vote Raises Questions of International Law

Experts say self-determination, as defined and protected by international law, confined narrowly to independence movements in process of de-colonization More

Video Whaling Summit Votes to Uphold Ban on Japan Whale Hunt

Conservationists hail ruling as a victory, but Tokyo says it will submit revised plans for a whale hunt in 2015 More

Annual Military Exercise Takes on New Meaning for Ukraine Troops

Troops from 15 nations participating in annual event, 'Rapid Trident' in western Ukraine More

This forum has been closed.
Comments
     
There are no comments in this forum. Be first and add one

Featured Videos

Your JavaScript is turned off or you have an old version of Adobe's Flash Player. Get the latest Flash player.
Russian Economy Reeling After New Western Sanctionsi
X
September 18, 2014 2:28 AM
A new wave of Western sanctions is hitting Russia’s economy hard. State-owned energy firms continue to bleed profits and Russia’s national currency plunged to a new low this week after the U.S. and the European Union announced new sanctions to punish Russia's aggressive stance in eastern Ukraine. But as Mil Arcega reports, the sanctions could also prove costly for European and American companies.
Video

Video Russian Economy Reeling After New Western Sanctions

A new wave of Western sanctions is hitting Russia’s economy hard. State-owned energy firms continue to bleed profits and Russia’s national currency plunged to a new low this week after the U.S. and the European Union announced new sanctions to punish Russia's aggressive stance in eastern Ukraine. But as Mil Arcega reports, the sanctions could also prove costly for European and American companies.
Video

Video Belgian Researchers Discover Way to Block Cancer Metastasis

Cancer remains one of the deadliest diseases, despite many new methods to combat it. Modern medicine has treatments to prevent the growth of primary tumor cells. But most cancer deaths are caused by metastasis, the stage when primary tumor cells change and move to other parts of the body. A team of Belgian scientists says it has found a way to prevent that process. Zlatica Hoke has more.
Video

Video Mogadishu's Flood of Foreign Workers Leaves Somalis Out of Work

Unemployment and conflict has forced many young Somalians out of the country in search of a better life. But a newfound stability in the once-lawless nation has created hope — and jobs — which, some say, are too often being filled by foreigners. Abdulaziz Billow reports from Mogadishu.
Video

Video A Dinosaur Fit for Land and Water

Residents and tourists in Washington D.C. can now examine a life-size replica of an unusual dinosaur that lived almost a hundred million years ago in northern Africa. Scientists say studying the behemoth named Spinosaurus helps them better understand how some prehistoric animals adapted to life on land and in water. The Spinosaurus replica is on display at the National Geographic museum. VOA’s George Putic has more.
Video

Video Iraqi Kurdistan Church Helps Christian Children Cope find shelter in churches in the Kurdish capital, Irbil

In the past six weeks, tens of thousands of Iraqi Christians have been forced to flee their homes by Islamic State militants and find shelter in churches in the Kurdish capital, Irbil. Despite U.S. airstrikes in the region, the prospect of people returning home is still very low and concerns are starting to grow over the impact this is having on the displaced youth. Sebastian Meyer reports from Irbil on how one church is coping.
Video

Video NASA Picks Boeing, SpaceX to Carry Astronauts Into Space

The U.S. space agency, NASA, has chosen Boeing and SpaceX companies to build the next generation of spacecraft that will carry U.S. astronauts to the International Space Station by the year 2017. The deal with private industry enables NASA to end its dependence on Russia to send space crews into low Earth orbit and back. Zlatica Hoke has more.
Video

Video Future of Ukrainian Former President's Estate Uncertain

More than six months after Ukraine's former President Viktor Yanukovych fled revolution to Russia, authorities have yet to gain control of his palatial estate. Protesters occupy the grounds and opened it to tourists but they are also refusing to turn it over to the state. VOA's Daniel Schearf reports from Mezhigirya, just north of Kyiv.
Video

Video China Muslims Work to Change Perceptions After Knife Attacks

China says its has sentenced three men to death and one woman to life in prison for a deadly knife attack in March that left more than 30 dead and 140 injured. Beijing says Muslim militants from China's restive western region of Xinjiang carried out the attacks. Now, more than six months after the incident, residents in the city are still coping with the aftermath. VOA's Bill Ide has more from Kunming.


Carnage and mayhem are part of daily life in northern Nigeria, the result of a terror campaign by the Islamist group Boko Haram. Fears are growing that Nigeria’s government may not know how to counter it, and may be making things worse. More

AppleAndroid