Start Antiretroviral Therapy Earlier in HIV

April 8, 2006

"The current recommendation for starting highly active antiretroviral therapy (HAART) in patients with HIV infection when the CD4 cell count falls below 200/mm2 has been fairly well etched in stone," said Howard Libman, MD. However, available evidence demonstrates strongly that patients benefit in tangible ways from having treatment started earlier," said Libman, director, HIV program, Healthcare Associates, Beth Israel Deaconess Medical Center, Boston.

"The current recommendation for starting highly active antiretroviral therapy (HAART) in patients with HIV infection when the CD4 cell count falls below 200/mm2 has been fairly well etched in stone," said Howard Libman, MD. However, available evidence demonstrates strongly that patients benefit in tangible ways from having treatment started earlier," said Libman, director, HIV program, Healthcare Associates, Beth Israel Deaconess Medical Center, Boston.

Libman pointed to two studies presented earlier this year at the Conference on Retrovirus and Opportunistic Infection. One modeled data from the ART Cohort Collaborative study that included 10,855 patients. During the available follow-up, 934 of those subjects progressed to AIDS or died. When the outcomes were analyzed with the patients divided according to whether HAART was started at a CD4 cell count 2, the risks both for developing AIDS and for death were threefold higher among patients who started treatment later versus earlier.

When comparing groups who had HAART started when their CD4 cell count was 200-350/mm2 versus 351-500/mm2, there appeared to be some morbidity benefit for a more aggressive approach but no clear difference in mortality risk.

The second study analyzed data from the HIV Outpatient Study that includes about 8,000 patients followed prospectively since 1993. It found patients who started HAART at a CD4 cell count of 200/mm2 or higher had a lower mortality rate, a lower rate of opportunistic infections, and a better CD4 cell count response relative to those started on treatment with a CD4 cell count below 200/mm2.

Interestingly, earlier treatment was also associated with lower incidences of renal insufficiency, peripheral neuropathy, and lipoatrophy.

"One limitation of this study is that only a minority of patients had paired CD4 cell counts and HIV viral load determinations, and I cannot explain the findings with respect to rates of the complications that are typically associated with antiretroviral therapy. However, we have known for several years that earlier initiation of HAART tends to result in a greater rise in CD4 cell counts," Dr. Libman said.