Should AIDS therapy be used earlier than current guidelines recommend?

September 01, 2004

Highly active antiretroviral therapy (HAART) has been shown to delay progression of AIDS and reduce mortality, yet the optimal time to start it is unknown. Current federal and other guidelines suggest initiating therapy when counts are between 200/ìL (200 per microliter) and 350/ìL. Those levels may be too low, however, and therapy begun too late for optimal results, according to a study of injection drug users in the September 15 issue of The Journal of Infectious Diseases, now available online.

The authors, Cun-lin Wang and coworkers at Johns Hopkins University and The New York Academy of Medicine, studied both HIV-positive and HIV-negative injection drug users in order to compare data in persons with the same mortality risk category. The expectation was that such a comparison would provide a more accurate picture than heretofore reported of the degree to which the survival rate associated with HAART may be improved to approximate that of an uninfected population.

A total of 1,503 subjects were followed from 1997 to 2000; 920 were HIV-negative throughout the study period, 556 were HIV-infected at the outset, and 27 became HIV-infected during the study. The investigators stratified subjects according to HIV status, HAART use, and CD4 cell level at HAART initiation. Analysis of survival accounted for all-cause mortality, AIDS-related mortality, and non-AIDS-related mortality and was adjusted for factors associated with HAART access, such as active drug use or enrollment in a drug treatment program.

The results: Mortality among HIV-infected injection drug users with CD4 cell counts greater than 350/ìL who received HAART (24.1/1,000 person-years) was similar to that of HIV-seronegative injection drug users (19.9/1,000). Furthermore, both groups had lower mortality than HIV-infected subjects with CD4 cell counts greater than 350/ìL who did not receive HAART (43/1,000) and those with CD4 counts between 200/ìL and 350/ìL who did receive such therapy (50.5/1,000). "Assuming that the goal of HIV treatment is to produce outcomes similar to those seen in HIV-negative persons," said the investigators, "our results suggest initiating or switching to HAART at higher CD4 counts than in current recommendations."

In an accompanying editorial, Mauro Schechter of the Federal University of Rio de Janeiro, Brazil, characterized the study as "an important contribution to the debate on when to start therapy." He noted, however, that the findings had several limitations, including the study's observational design and lack of randomization, incomplete information on socio-behavioral differences in the study groups, and no data on adherence to treatment. Cautioning that evidence is mixed regarding the CD4 cell level at which to begin HAART, he concluded that it remains reasonable to start therapy for most asymptomatic patients with HIV infection whose CD4 cell counts are less than 350/ìL but that guidelines on when to initiate therapy may change as more data emerge.
Founded in 1904, The Journal of Infectious Diseases is the premier publication in the Western Hemisphere for original research on the pathogenesis, diagnosis, and treatment of infectious diseases; on the microbes that cause them; and on disorders of host immune mechanisms. Articles in JID include research results from microbiology, immunology, epidemiology, and related disciplines. It is published under the auspices of the Infectious Diseases Society of America (IDSA), a professional society based in Alexandria, Va., representing more than 7,500 physicians and scientists who specialize in infectious diseases. (For more information, visit Nested within the IDSA, the HIV Medicine Association (HIVMA) is the professional home for more than 2,600 physicians, scientists and other health care professionals dedicated to the field of HIV/AIDS. HIVMA promotes quality in HIV care and advocates policies that ensure a comprehensive and humane response to the AIDS pandemic informed by science and social justice. (For more information, visit

Infectious Diseases Society of America

Related Aids Articles from Brightsurf:

Developing a new vaccination strategy against AIDS
Infection researchers from the German Primate Center (DPZ) -- Leibniz Institute for Primate Research have in cooperation with international colleagues tested a new vaccination strategy against the HIV-related simian immunodeficiency virus (SIV) in rhesus monkeys.

HIV-AIDS: Following your gut
Researchers find a way to reduce replication of the AIDS virus in the gastrointestinal tract.

A path toward ending AIDS in the US by 2025
Using prevention surveillance data to model rates of HIV incidence, prevalence and mortality, investigators at Brigham and Women's Hospital and Johns Hopkins Bloomberg School of Public Health set targets, specifically a decrease in new infections to 21,000 by 2020 and to 12,000 by 2025, that would mark a transition toward ending the HIV/AIDS epidemic.

What does it take for an AIDS virus to infect a person?
Researchers examined the characteristics of HIV-1 strains that were successful in traversing the genital mucosa that forms a boundary to entry by viruses and bacteria.

How AIDS conquered North America
A new technique that allowed researchers to analyze genetic material from serum samples of HIV patients taken before AIDS was known provides a glimpse of unprecedented detail into the beginnings of the AIDS epidemic in North America.

New research could help build better hearing aids
Scientists at Binghamton University, State University of New York want to improve sensor technology critical to billions of devices made every year.

NY State Department of Health AIDS Institute funds HIV/AIDS prevention in high-risk youth
NewYork-Presbyterian's Comprehensive Health Program and Project STAY, an initiative of the Harlem Heath Promotion Center (HHPC) at Columbia University's Mailman School of Public Health has received two grants totaling more than $3.75 million from the New York State Department of Health AIDS Institute for their continued efforts to prevent HIV/AIDS in at-risk youth.

A new way to nip AIDS in the bud
When new HIV particles bud from an infected cell, the enzyme protease activates to help the viruses infect more cells.

AIDS research prize for Warwick academic
A researcher at the University of Warwick has received international recognition for his contribution to AIDS research.

Insects inspire next generation of hearing aids
An insect-inspired microphone that can tackle the problem of locating sounds and eliminate background noise is set to revolutionize modern-day hearing aid systems.

Read More: Aids News and Aids Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to