February 7, 2001
Yesterday I discussed the whole issue of how to treat acute HIV infection, a very muddy field, where things are not quite clear -- except perhaps for patients with very early infection, like the patients Rosenberg and Walker have treated in Boston (see abstract 367).
In this study, the many, many authors (believe it or not, nineteen of them!) looked at the lymph nodes of patients with acute infection with HIV, and compared them to the lymph nodes of patients chronically infected with HIV and not treated with HAART. They did immunohistochemistry and quantification of HIV RNA in the lymph nodes. In that regard, this study is not very different from others presented in other conferences over the last few years, with smaller sample sizes. What they found was that in spite of having a relatively high viral load in plasma, the patients with acute infection did not harbor that much virus in their lymph nodes, and did not have much trapping of HIV in the dentritic network. (Note for the uninitiated: The dentritic cells of the lymph nodes "present" the antigens to the CD4 cells.)
From there, they concluded that this finding supports the early treatment of HIV because treatment would prevent the spreading of the virus in the lymph nodes. I think this is a big jump since they did not prove that therapy prevents this from happening, and it is not clear that even if it does not happen, that that has any significant clinical impact in the long run. So far, the only group that has demonstrated a possible clinical improvement with very early intervention in this setting is Bruce Walker's group in Boston. The rest of the studies, especially the ones in which therapy was administered later, are really a mixed bag.
As I said yesterday, the management of acute HIV infection is still in flux. The need for very early intervention is going to be complicated because there is a significant prevalence of drug resistance being transmitted, and one needs to know the genotype of the virus being treated in this setting, as Susan Little has demonstrated in studies in multiple U.S. cities. Genotypes can take several days to be completed, which could delay therapy and make it less effective. This is a real conundrum -- unless we start giving much more aggressive therapy initially until the results of genotypes are available . . . something really not very palatable.
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