In the news ... 2008

Growing evidence supports early treatment

by Paul Dalton, June 24, 2008

A study recently reported in the journal, AIDS, found that people who started taking HIV medicines with higher CD4 cell counts were more likely to have their immune systems restored to near normal levels. This study adds to a growing body of data on the benefits of early anti-HIV treatment.

The study
The researchers looked at people from the AIDS Therapy Evaluation Project Netherlands (ATHENA) cohort starting HIV drugs for the first time and followed them for 7 years. They looked at how likely people were to achieve CD4 counts greater or equal to 800, which is considered normal for an HIV-negative person.

The study participants were 75% male and 63% white. About half were men who have sex with men, 35% heterosexual and 4% injection drug users. Average CD4 count at the start when starting HIV treatment was 190. Just under 20% started with CD4 counts under 50, while only 7% started with counts above 500.

The results
Most people in the cohort experienced significant increases in their CD4 counts. Not surprisingly, there was a very strong relationship between a person’s CD4 cell count when they started and their likelihood of achieving a count of over 800. Those who started treatment with CD4 counts over 500 were over 23 times more likely to achieve counts of 800 than people who started with counts below 50.

The difference was also significant for groups with much smaller differences in their CD4 counts before starting therapy. Those who started with counts between 350–500 were 2.76 times more likely to achieve counts above 800 than those who started with counts between 200–350.

The same was seen in people with highest and lowest counts when they started. For example, people who started treatment with CD4 counts between 50 and 200 were about twice as likely as those who started below 50 to achieve counts above 800. Likewise, people who started with counts above 500 were 2.4 times more likely than those who started between 200 and 350.

There were several other interesting findings:

• Women were about 26% more likely than men to get to above 800. Injection drug users were about 30% less likely.
• No real differences were seen by ethnic groups.
• The older a person was at the time they started HIV treatment, the less likely they were to see their counts rise above 800.
  
  People who were over 50 when they started meds were over twice as likely to have their CD4 counts plateau at below 800 as those who started at a younger age.

• Having detectable levels of HIV at any time during the study resulted in a 4.69 times less chance of having CD4 levels above 800.

What does this all mean?
Overall, the findings of this study are not surprising. Maybe the most important finding was the big difference in outcomes for people who started treatment with CD4 counts between 350–500 vs. those who started between 200–350. It is relatively uncommon for people to start HIV treatment at either high (over 500) or low (below 200). Many people begin with counts somewhere between 200–500. This study shows they are more likely to achieve high CD4 counts if they start with counts above 350.

The affects of age on treatment outcomes is of growing importance. As we age, our immune systems’ ability to recover wanes. This study highlights this fact and argues for earlier treatment for people over 50 living with HIV.

This study will add to the ongoing debate on the best time to start HIV treatment. The current Federal Guidelines recommend starting treatment before your CD4 count falls to 350. It also discusses the possible benefits and risks of starting at higher CD4 counts, but does not make a recommendation.

Without a large, definitive study aimed at determining the best time to start treatments, doctors, activists and people with HIV have to piece together results from other studies, like this one, to guide them on this important question. If one of the main goals of HIV treatment is to restore a person’s immune system to as close to normal as possible, this study strongly supports earlier treatment. This potential benefit must be weighed against the risks and difficulties of HIV treatment. This equation is growing more favorable toward earlier treatment as HIV drugs become more tolerable and convenient.