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

Photogallery Oxfam: Ebola Could Be 'Disaster of Our Generation'

Meanwhile, Fidel Castro, the former leader of Cuba, says the Caribbean island nation will 'gladly cooperate' with the US in the fight against Ebola in West Africa More

Multimedia Kobani Fighting Sends 400,000 Refugees to Turkey

Refugees receive help from Turkish authorities and individuals, but say much more is needed More

India’s Ruling Nationalist Party Makes Gains in Regional Elections

Bharatiya Janata Party’s huge margin over its rivals puts it on course to form governments in the northern Haryana and western Maharashtra states 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.
Exclusive: American Joins Kurds' Anti-IS Fighti
X
Zana Omer
October 18, 2014 6:37 PM
The United States and other Western nations have expressed alarm about their citizens joining Islamic State forces in Syria and Iraq. In a rare counterpoint to the phenomenon, an American has taken up arms with the militants' Syrian Kurdish opponents. Elizabeth Arrott has more in this exclusive profile by VOA Kurdish reporter Zana Omer in Ras al Ayn, Syria.
Video

Video Exclusive: American Joins Kurds' Anti-IS Fight

The United States and other Western nations have expressed alarm about their citizens joining Islamic State forces in Syria and Iraq. In a rare counterpoint to the phenomenon, an American has taken up arms with the militants' Syrian Kurdish opponents. Elizabeth Arrott has more in this exclusive profile by VOA Kurdish reporter Zana Omer in Ras al Ayn, Syria.
Video

Video South Korea Confronts Violence Within Military Ranks

Every able-bodied South Korean male between 18 and 35 must serve for 21 to 36 months in the country’s armed forces, depending upon the specific branch. For many, service is a rite of passage to manhood. But there are growing concerns that bullying and violence come along with the tradition. Reporter Jason Strother has more from Seoul.
Video

Video Comanche People Maintain Pride in Their Heritage

The Comanche (Indian nation) once were called the “Lords of the Plains,” with an empire that included half the land area of current day Texas, large parts of Oklahoma, New Mexico, Kansas and Colorado.The fierceness and battle prowess of these warriors on horseback delayed the settlement of most of West Texas for four decades. VOA’s Greg Flakus reports from Lawton, Oklahoma, that while their warrior days are over, the 15,000 members of the Comanche Nation remain a proud people.
Video

Video Turkey Campus Attacks Raise Islamic Radicalization Fears

Concerns are growing in Turkey of Islamic radicalization at some universities, after clashes between supporters of the jihadist group Islamic State (IS) or ISIS, and those opposed to the extremists. Pro-jihadist literature is on sale openly on the streets of Istanbul. Critics accuse the government of turning a blind eye to radicalism at home, while Kurds accuse the president of supporting IS - a charge strongly denied. Henry Ridgwell reports from London.
Video

Video Syrian Defector Leaks Shocking Photos of Torture Victims

Shocking photographs purporting to show Syrian torture victims are on display at the U.S. Holocaust Memorial Museum in Washington. The museum says the graphic images are among thousands of photographs recently smuggled out of Syria by a military policeman-turned-defector. As VOA reporter Julie Taboh reports, the museum says the photos provide further evidence of atrocities committed by the government of Syrian President Bashar al-Assad against its own people.
Video

Video Drought-Stricken California Considers Upgrading Water System

A three-year drought in California is causing a water shortage that is being felt on farms and cities throughout the state. As VOA's Mike O’Sullivan reports, water experts, consumers and farmers say California needs to make changes to cope with an uncertain future.
Video

Video TechShop Puts High-tech Dreams Within Reach

Square, a business app and card reader, makes it possible to do credit card transactions through cell phones. But what made Square possible? VOA’s Adrianna Zhang and Enming Liu have the answer.
Video

Video Church for Atheists Goes Global

Atheists, by definition, do not believe in God. So they should have no need of a church. But two years ago, a pair of British stand-up comedians decided to create one. Sanderson Jones and Pippa Evans told the BBC they envisioned “something like church but without God". Their “Sunday Assembly” movement has grown from a single congregation in London to dozens of churches around the world. Reporter Mike Osborne visited with the members of a Sunday Assembly that now meets regularly in Nashville.
Video

Video Robot Locates Unexploded Underwater Mines

Many educators believe that hands-on experience is the best way to learn. Proving that the method works is a project developed by a group of students at the Stevens Institute of Technology, in Hoboken, New Jersey. They rose up to a challenge posted by the U.S. Department of Defense and successfully designed and built an underwater robot for locating submerged unexploded ordnance. VOA’s George Putic reports.
Video

Video Liberia's JFK Hospital Reopens After Temporary Ebola Exposure

JFK Hospital is Liberia’s largest and one of its oldest medical facilities. The hospital had to close temporarily following the deaths of two leading doctors from Ebola. It is now getting back on its feet, with the maternity ward being the first section to reopen. Benno Muchler has more for VOA News from Monrovia.
Video

Video Hong Kong Protests Expose Generation Gap

Most of the tens of thousands of protesters in Hong Kong are students seeking democracy. Idealistic youths say while the older generation worries about the present, they are fighting for the territory's future. VOA's Daniel Schearf reports from Hong Kong.
Video

Video Liberians Living in US Struggle From Afar as Ebola Ravages Homeland

More than 8,000 Liberians live in New York City, more than in any other city outside of Liberia itself. As VOA’s Bernard Shusman reports, with the Ebola virus ravaging their homeland, there is no peace of mind for these New Yorkers.
Video

Video Kurds See War-Ravaged Kobani As Political, Emotional Heartland

Intense fighting is continuing between Islamic State militants -- also known as ISIS or ISIL -- and Kurdish forces around the Syrian town of Kobani, on the Turkish border. The U.S. said it carried out at least nine airstrikes against Islamic State positions Friday. Meanwhile the U.N. has warned that hundreds of civilians would be massacred if the town falls to the militants. Henry Ridgwell looks at the strategic significance of the city.

All About America

AppleAndroid