Earlier Antiretroviral Therapy Cuts HIV Patients Risk of Death
In a presentation at the 18th International AIDS Conference 2010 in Vienna, early treatment with antiretroviral therapy (ART) – even before symptoms start - can cut risk of death for HIV patients by about 75% according to new research published by the International AIDS Society/USA Antiretroviral Therapy Guidelines Panel. The study also found that early ART reduces the likelihood of tuberculosis by 50%.
The trial, conducted from 2005 to 2008, included 816 HIV-positive patients in Haiti. They were divided based on their CD4 cell counts. CD4 cells are immune system cells targeted by HIV, so concentrations in the blood are a key indicator of disease progression. Normal levels in a healthy individual are at least 500 and can range as high as 1,500.
About half of the patients were given the standard treatment of ART when CD4 counts were greater than 200 but less than 350. The other group received an identical regimen of ART but it was initiated when CD4 counts were at or below 200.
Among those receiving the standard treatment, 23 participants died compared to 6 deaths among those who received earlier treatment. Thirty-six patients in the standard treatment group contracted tuberculosis, compared to 18 in the early-treatment group. Tuberculosis is a leading cause of death among HIV/AIDS patients.
The World Health Organization estimates that HIV-related deaths could be reduced by 20 percent between 2010 and 2015 if the new treatment guidelines were broadly implemented. Evidence from scientific studies also shows that earlier treatment can be an effective way of preventing the virus from spreading.
As a result of the findings, WHO is now recommending that physicians start ART earlier – at 350 cells or less per microliter for patients with confirmed disease. The guidelines also suggest that physicians consider patient readiness as a key consideration to initiating earlier therapy – even at CD4 levels of 500 or less - as “there is no CD4 cell count that would prevent the initiation of therapy.”
"The prominence of non-AIDS events as a major cause of morbidity and mortality in those with ongoing HIV replication suggests that early ART initiation may further improve the quality and length of life for persons living with HIV," the panel members wrote.
The new 2010 guidelines, which will be published in the July 21 HIV/AIDS theme issue of the Journal of the American Medical Association, also include the following recommendations:
• ART is also recommended for patients who are pregnant, older than 60, or have an active or high risk for cardiovascular disease, and for those with hepatitis B or C infections, HIV-associated kidney disease, opportunistic diseases or symptomatic primary HIV infection.
• ART should also be prescribed in cases where there is a high risk for HIV transmission, such as couples with one HIV-infected and one HIV-free partner.
• Once started, ART should be continued, except when being used in a clinical trial.
• Risk-reduction counseling should be a routine part of care.
At the current pricing, 2 years of ART cost approximately $400 per person, but with the decrease in death rate and the reduced incidence of active tuberculosis the cost will be offset by the reduced consumption of resources later, such as time of health care workers caring for sicker patients.
"Advances in ART have shown that AIDS, as traditionally defined, can be prevented. One of the greatest challenges is that full implementation of these guidelines will require addressing social and structural barriers to diagnosis and care, as well as the pervasive stigma and discrimination associated with an HIV diagnosis," the panel concluded.
According to WHO data, although 33.4 million people have HIV/AIDS, only an estimated 5.2 million people were being treated at the end of 2009.
Thompson MA, et al "Antiretroviral treatment of adult HIV infection: 2010 Recommendations of the International AIDS Society-USA Panel." JAMA 2010; 304(3): 321-333.