The earlier you start on ARVs the better
Mar 07, 2006
WHEN it comes to fighting the AIDS virus, the sooner patients start taking powerful drug cocktails, the better, even when it comes to side-effects known as toxicities, US researchers reported.
WHEN it comes to fighting the AIDS virus, the sooner patients start taking powerful drug cocktails, the better, even when it comes to side-effects known as toxicities, US researchers reported.
Deaths, the rate of opportunistic infections and side effects were the lowest in patients who started treatment early while their immune systems were still relatively intact, the team at the University of Colorado Health Sciences Center and the Centers for Disease Control and Prevention found.
“Earlier was better in almost everything we looked at,†said Dr. Kenneth Lichtenstein of the University of Colorado. “If you stayed on treatment and had started earlier, you had the best outcome.â€
The findings negate the government policy that people in Uganda start on HIV treatment when their CD4 falls to 200 and below. Dr Paul Semugoma, a medical officer at International Medical Centre, Kampala, concurs with the research. He says patients ought to start on HIV treatment when their CD4 count is still high.
Semugoma says there are several criteria that determine when one starts on ARVs.
“Ideally, we also ought to look at the viral load and onset of AIDS-defining illnesses besides the CD4 count, as crucial factors in using ARVs,†Semugoma says. “Patients with a high viral load need to be put on ARVs even when their CD4 count is still high.â€
The research faults the current guidelines that recommend delaying therapy as based on incorrect assumptions that starting drugs early worsens toxicity. The researchers used the medical records of 2,304 HIV-positive patients in the US in between 1996 and 2005.
They looked for three common treatment-related toxicities – kidney insufficiency, damage on the nervous system (neuropathy) and the loss of fat under the skin (lipoatrophy). They broke the patients down into five groups based on the number of CD4 T-cells they had – known as the CD4 count. As HIV infection worsens, the virus attacks these immune cells and the count goes down. All the patients were on drug cocktails known as Highly Active Antiretroviral Therapy (HAART). These three and four drug mixes can keep patients healthy if taken properly.
Higher cell counts
Patients are generally told to start HAART at a CD4 cell count of 200 or below. But some patients started treatment with cell counts of 350, 500 or higher.
Those patients who started treatment at CD4 counts above 350 were at least 60% less likely to develop kidney insufficiency, 30% less likely to have damage to the nervous system, and 60% less likely to develop lipoatrophy than patients who started at a CD4 count of 200 cells or below, the research found.
Lichtenstein said it appeared the drug was the most active in and around cells when there were the fewest CD4 cells.
Inflammation seems to be an important factor, he said. “The state of inflammation associated with disease brings up the toxicity,†he said.
According to these findings, Lichtenstein said there is no reason to delay HAART treatment and to delay getting tested for HIV. Drug companies have simplified the regimens so that patients can often take just two pills a day. In the past, patients often had to juggle 20 pills, taken at specified times of day, some with meals.
The side-effects also were debilitating, ranging from diarrhoea and nausea to serious organ damage.
And there were fewer choices of drugs, so patients often were wise in hesitating to start therapy until they really ‘needed’ it, because if the virus became resistant to a drug, a patient had few others to turn to. “Now there are four classes of drugs, soon to be five classes.†They all attack the virus at different points of its life cycle. None destroy it but they can suppress it almost completely if taken in the right combinations.
Additional reporting by Timothy Makokha
Deaths, the rate of opportunistic infections and side effects were the lowest in patients who started treatment early while their immune systems were still relatively intact, the team at the University of Colorado Health Sciences Center and the Centers for Disease Control and Prevention found.
“Earlier was better in almost everything we looked at,†said Dr. Kenneth Lichtenstein of the University of Colorado. “If you stayed on treatment and had started earlier, you had the best outcome.â€
The findings negate the government policy that people in Uganda start on HIV treatment when their CD4 falls to 200 and below. Dr Paul Semugoma, a medical officer at International Medical Centre, Kampala, concurs with the research. He says patients ought to start on HIV treatment when their CD4 count is still high.
Semugoma says there are several criteria that determine when one starts on ARVs.
“Ideally, we also ought to look at the viral load and onset of AIDS-defining illnesses besides the CD4 count, as crucial factors in using ARVs,†Semugoma says. “Patients with a high viral load need to be put on ARVs even when their CD4 count is still high.â€
The research faults the current guidelines that recommend delaying therapy as based on incorrect assumptions that starting drugs early worsens toxicity. The researchers used the medical records of 2,304 HIV-positive patients in the US in between 1996 and 2005.
They looked for three common treatment-related toxicities – kidney insufficiency, damage on the nervous system (neuropathy) and the loss of fat under the skin (lipoatrophy). They broke the patients down into five groups based on the number of CD4 T-cells they had – known as the CD4 count. As HIV infection worsens, the virus attacks these immune cells and the count goes down. All the patients were on drug cocktails known as Highly Active Antiretroviral Therapy (HAART). These three and four drug mixes can keep patients healthy if taken properly.
Higher cell counts
Patients are generally told to start HAART at a CD4 cell count of 200 or below. But some patients started treatment with cell counts of 350, 500 or higher.
Those patients who started treatment at CD4 counts above 350 were at least 60% less likely to develop kidney insufficiency, 30% less likely to have damage to the nervous system, and 60% less likely to develop lipoatrophy than patients who started at a CD4 count of 200 cells or below, the research found.
Lichtenstein said it appeared the drug was the most active in and around cells when there were the fewest CD4 cells.
Inflammation seems to be an important factor, he said. “The state of inflammation associated with disease brings up the toxicity,†he said.
According to these findings, Lichtenstein said there is no reason to delay HAART treatment and to delay getting tested for HIV. Drug companies have simplified the regimens so that patients can often take just two pills a day. In the past, patients often had to juggle 20 pills, taken at specified times of day, some with meals.
The side-effects also were debilitating, ranging from diarrhoea and nausea to serious organ damage.
And there were fewer choices of drugs, so patients often were wise in hesitating to start therapy until they really ‘needed’ it, because if the virus became resistant to a drug, a patient had few others to turn to. “Now there are four classes of drugs, soon to be five classes.†They all attack the virus at different points of its life cycle. None destroy it but they can suppress it almost completely if taken in the right combinations.
Additional reporting by Timothy Makokha