Treating HIV: The Earlier, the Better

June 2nd, 2009 | Sources: NEJM, NY Times


For years, physicians have debated when to start therapy for HIV-infected patients. Starting it early might delay, perhaps indefinitely, progression from a quiescent carrier state to the full blown syndrome, but it exposes patients to unpleasant, sometimes life-threatening side effects.

sheddingsomelightA study by Mari Kitahata and colleagues may have settled the argument in favor of early drug treatment.

The scientists tracked survival in 17,517 asymptomatic HIV-infected patients who started antiretroviral therapy at different points in the course of their disease, as determined by serum CD4 cell counts.

About a quarter of the subjects began therapy when their CD4 counts were in the 351- 500 range, and the remainder started therapy only after counts dropped to 350 or less.

The mortality risk was 69% higher in the latter group. These findings were confirmed in a second, separate cohort.

The write-up appears in the New England Journal of Medicine.

“This has been one of the most important questions in the last decade: what the optimal timing is for starting therapy,” Kitahata told the New York Times.

“Our study provides evidence that patients would live longer if antiretroviral treatment was begun when their CD4 count was above 350,” added Kitahata, who is director of clinical epidemiology at the Center for AIDS and STDs at the University of Washington.

National guidelines recommend beginning therapy in asymptomatic patients when CD4 counts drop below 350.


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