January 16, 2013
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
Management of recently acquired HIV infection -- especially acute HIV, pre-seroconversion -- has long been controversial, with the risks and benefits of treatment versus observation debated now for nearly two decades.
(Yes, it's been that long since the publication of this controlled trial of zidovudine monotherapy. Amazing.)
On the risk side of the equation is the toxicity of lifelong treatment, especially since some patients may have normal or near-normal CD4 cell counts after recovery from acute HIV, and may remain asymptomatic for many years. Benefits include preservation of immunologic function, reduction in transmission risk to others, and even potentially a reduction in the HIV reservoir -- the last making patients who are treated for recently acquired HIV of particular interest for HIV cure strategies.
Now, two studies have been published in the New England Journal of Medicine that strongly suggest that we manage early HIV infection the same way we do long-established disease -- that is, with antiretroviral therapy (surprise!), and the sooner it's started, the better.
There are of course limitations to these studies, most notably the non-randomized design and skewed demographics in the first, and the fact that treatment interruption makes both of the treatment strategies in the second study of limited relevance today. Furthermore, the various definitions of early HIV infection -- a problem which has plagued this field from the outset -- imply a very heterogeneous patient population: In the second study, some participants had acute symptomatic HIV infection pre-seroconversion at one extreme, and others were diagnosed solely based on a newly positive HIV antibody. And neither study had sufficiently long follow-up to provide hard clinical endpoints of the benefits of early treatment.
These limitations notwithstanding, there is a consistent message from the aggregate results, which is that treatment of early HIV infection -- and the earlier the better -- is associated with significant improvements in the most important surrogate markers of HIV disease, the CD4 cell count, and the HIV viral load. For these outcomes alone, early treatment is warranted -- especially since we're generally recommending treatment for everyone else with HIV already!
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.
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