Earlier Treatment for a Longer Life?

It might be hard to believe, but in the United States 40% of people who are newly diagnosed with HIV advance to an AIDS-defining condition within one year. This highlights the dire problem that people are testing very late in their disease progression and are only able to start on their medications when their T-cell counts are low. In fact, the average T-cell count of Americans newly diagnosed with HIV is only 187. Remember that a T-cell count of less than 200 is an AIDS-defining condition, but more important, it also increases a person's likelihood of developing certain opportunistic infections. Clearly, health care reform needs to address this issue by making HIV testing routine for everyone. But new data from clinical trials have begun to hint that starting anti-HIV meds when T-cell counts are higher (greater than 500) than current recommendations could be beneficial and could prevent many of the complications of untreated HIV. The reasons for starting meds early include preventing not just diseases related to HIV but non-AIDS-related complications -- like heart disease, kidney damage, neuropathy (pain and burning in the feet or hands), and anemia (low red-blood-cell counts). One HIV outpatient study being done in Baltimore has shown that the rates of these complications were much higher when patients started on anti-HIV medications when their T-cell counts were lower than 200, compared to those who started when their counts were greater than 200. Current guidelines recommend starting HIV-positive people on medications when their T-cell count drops below 350. Newer data, reported at this year's Conference on Retroviruses and Opportunistic Infections, suggest that treatment should be started when the count is greater than 500. Why so high? When investigators looked at 22 different trials of approximately 9,000 patients they found that the ones who started meds when their counts were less than 500 had a greater than 90% increased risk of death! And the majority of these deaths were due to non-AIDS-related conditions, like heart disease or cancer as well as liver and kidney failure. Although starting treatment so early may prevent a lot of damage that HIV does, the risk of someone getting very sick if he or she waits to start when T cells drop to just below 350 is still quite small. Further, once you commit to starting on therapy, there may be issues with adherence and toxicities to the medications. Fortunately, current regimens are more convenient (some are once-daily, some even a single pill) and are well-tolerated. The decision of when to start on anti-HIV medications is a very important one. But with newer studies suggesting that untreated HIV causes a lot of inflammation and that that may contribute to heart and kidney disease as well as to increased rates of cancer, starting HIV therapy at a higher T-cell count could very well prevent some of these complications. Urbina is an HIV specialist and the medical director of HIV education and training at St. Vincent's Comprehensive HIV Center as well as an associate professor of medicine and an associate professor of clinical public health at New York Medical College.