Is It Time to Treat at 500-Plus T Cells?

One of the hot topics at the 16th Conference on Retroviruses and Opportunistic Infections, held in Montreal in February, was a presentation of data from the North American AIDS Cohort Collaboration on Research and Design that showed an advantage to starting HIV treatment when CD4 counts are still above 500. The NA-ACCORD is a collection of population studies conducted in the United States and Canada between 1996 and 2006 that identified about 9,100 patients who had more than 500 CD4 cells. It then compared people who started anti-HIV treatment when their CD4 counts were still greater than 500 to those who started treatment in the 350 to 500 range. The data showed that the over-500 group had 60% fewer deaths'from either AIDS-related or non-AIDS causes. These results are in agreement with the NA-ACCORD study comparing the effects of starting HIV treatment above (versus below) 350 that was reported in October 2008; it showed a 70% benefit in earlier treatment. Experts are quick to caution that this is an observational study, which means some unknown factors could have caused some patients to start early and others to start later. Although the investigators used sophisticated statistical analyses to control for any bias difference between the two groups, only a prospective double-blind study can provide an unequivocal answer to the question of how early to start treatment. That study, however, could take years to complete, require a very large number of patients, and consume millions of dollars. And since average T-cell count at the time of first HIV diagnosis is already down to 187 in the United States, many question whether that study would be worth it. Meanwhile, evidence continues to mount that uncontrolled HIV adds to the risk of non-AIDS-related illness and death. For example, the multicenter SMART study, which looked at treatment interruptions, showed more heart, liver, and kidney disease in patients who went off treatment compared to those who stayed on. Various treatment guidelines, which call for treatment to start when T-cell counts hit 350, already state that coinfection with hepatitis B or C or the presence of kidney or heart disease are indications to start treatment sooner. And now that current regimens are easier to take and have minimal if any toxicities, we may be about to enter a new era in HIV where everyone is treated as soon as they test positive. Bowers is an HIV specialist and is board-certified in family medicine. He is in private practice in New York City. Learn more about Bowers at https://www.danbowersmd.com