AIDS experts recommend earlier HIV treatment
An international panel of AIDS experts Sunday recommended earlier treatment for HIV infections in an effort to prevent the development not only of full-blown AIDS, but of other complications of infection as well. The International AIDS Society-USA Antiretroviral Therapy Guidelines Panel, which makes nonbinding recommendations about HIV treatment, had previously recommended that treatment be initiated when CD4 levels fall below 350 cells per cubic millimeter.
In an article Sunday in the Journal of the American Medical Assn. and a presentation at the International AIDS Conference in Vienna, the group said it is now recommending that treatment begin when levels fall below 500.
The CD4 cell is the immune system cell that is targeted by the AIDS virus. Normal levels in a healthy individual are at least 500 and can range as high as 1,500. Symptoms of AIDS, including opportunistic infections, typically begin when levels fall below 200, and researchers had previously believed that beginning treatment when levels fall below 350 could forestall most problems. Recent studies, however, have shown at least a 30% increased risk of death at levels between 350 and 500.
In the developing world, UNAIDS and other funding agencies have in the past recommended that treatment begin when levels fall below 200, at least in part because of limited resources. Earlier this week, however, the agency shifted its recommendation to call for treatment when levels fall below 350.
“Far too many HIV-infected persons present for medical care with advanced disease, both in wealthy and resource-limited settings,” the panel wrote. “Advances in [antiretroviral therapy] have shown that AIDS, as traditionally defined, can be prevented.”
It is never inappropriate to treat an HIV-infected individual, no matter what the CD4 level is, the panel said. Treatment should be begun immediately, no matter what the CD4 level, for patients with established AIDS; pregnant patients; those 60 and older; patients with co-existing hepatitis B or C infections; those with kidney disease; those with heart disease or a high risk of it; those with opportunistic infections; and when the patient’s partner is not infected and thus at risk of infection. Treatment should never be stopped except for a clinical trial.
Treatment should be begun with at least two drugs and possibly three, hopefully in fixed-dose combinations. Treatment should typically be begun with a combination of tenofovir plus emtricitabine; the third component should be efavirenz, atazanavir, darunavir or raltegravir. Blood virus levels should be monitored frequently and the medications changed if viral load increases or CD4 counts fall.