April 2, 2009
A study published Wednesday in the New England Journal of Medicine suggests that starting HIV-positive people on antiretroviral treatment earlier than what current guidelines recommend could reduce the risk of death, the Wall Street Journal's "Health Blog" reports (Goldstein, "Health Blog," Wall Street Journal, 4/1). Researchers in two separate analyses examined the medical records of about 17,000 HIV-positive people (Waters, Bloomberg, 4/1). They looked at participants' CD4+ T cell count, starting with 8,000 participants in the first analysis. The researchers compared patients who began antiretroviral treatment within six months of receiving a CD4 count between 351 and 500 with those who delayed starting treatment until after their CD4 count was 350 or less. The patients that delayed treatment had a 69% higher risk of death during the follow-up period.
For the second analysis, the researchers studied 9,000 patients, comparing those who began treatment six months within receiving a CD4 count of 500 or greater with those who delayed starting treatment until their CD4 count was below 500. The researchers found that there was a 94% higher risk of death among patients who delayed treatment ("Health Blog," Wall Street Journal, 4/1). Bloomberg reports that the study adds to growing support for changing current guidelines, which recommend starting HIV-positive people on antiretroviral treatment when CD4 counts fall below 350. Current guidelines also say that doctors can decide on an individual basis whether patients with CD4 counts above 350 should begin treatment. For several years, doctors and patients have struggled with when to begin antiretroviral treatment, which can have significant side effects such as nausea, stomach issues, changes in blood fat levels and altered mental processes, Bloomberg reports.
The study adds "weight to a growing body of research that suggests treating HIV at earlier stages can help save lives," Bloomberg reports. "The drugs are now safer and the evidence mounting from our data and other data suggests it makes sense to start therapy earlier," Richard Moore, study author and professor of medicine at Johns Hopkins Bloomberg School of Public Health, said. Jason Kantor -- an analyst with RBC Capital Markets in San Francisco -- said the study's findings are already known to many doctors but that they still are likely to spark increased use of antiretroviral treatment. Brad Hare, medical director of the University of California-San Francisco's Positive Health Program at San Francisco General Hospital, said the study provides "a scientific foundation for a practice that a lot of patients and doctors have already been doing, namely starting medications earlier."
Harvard Medical School researchers Paul Sax and Lindsey Baden write in an accompanying editorial that the findings cannot be considered conclusive because researchers did not randomly assign patients to begin treatment at different stages but analyzed patient records, Bloomberg reports. The editorial says, "The supportive evidence for the benefits of earlier therapy continues to increase," although the study did not "provide definitive proof that we should start antiretroviral therapy in all" HIV-positive patients (Bloomberg, 4/1). Sax and Baden also write that the participants who began treatment earlier might have differed from those who waited in ways that improved survival rates and were independent of when they initiated therapy. To address this, researchers should randomly assign patients to begin therapy earlier or later and determine which group fares better, the editorial says, noting that at least three such studies are ongoing or planned ("Health Blog," Wall Street Journal, 4/1). Hare said that the study will spark a discussion into changing current guidelines on when to begin treatment and whether the government should fund a randomized clinical trial. The study was sponsored by two federal agencies, including NIH (Bloomberg, 4/1).
Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily HIV/AIDS Report, search the archives, or sign up for email delivery at www.kaisernetwork.org/dailyreports/hiv. The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, a free service of the Kaiser Family Foundation, by The Advisory Board Company. © 2009 by The Advisory Board Company and Kaiser Family Foundation. All rights reserved.
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