British doctors are calling for HIV-infected patients to receive earlier treatment than is presently the norm.
Researchers have just published evidence that they say makes it imperative for patients to be treated before their immune systems crash below a commonly recognized threshold of damage inflicted by the AIDS virus.
Highly active antiretroviral therapy (HAART) began to overturn the automatic death sentence associated with AIDS after this powerful cocktail of drugs was introduced in 1996.
But the big question remained: When to start giving it to someone infected with the human immunodeficiency virus (HIV)?
Physicians have to balance the benefits of restoring immune defenses against the risk of the treatment's side effects, which can be toxic.
There is no universal guideline for when HAART should begin but a common recommendation is to start when there are fewer than 200-250 CD4 cells - key immune cells that are attacked by the virus - per microliter of blood.
Researchers now say this threshold is too low and that lives can be saved if HAART starts sooner, although supportive evidence is sketchy.
In a paper published in The Lancet, a team led by Jonathan Sterne of Britain's University of Bristol compared studies that followed more than 45,000 HIV-infected people in Europe and North America before and after the HAART era.
Those who began HAART when their CD4 count was below 350 cells per microliter were 28 percent likelier to develop AIDS or die prematurely than those who started when their CD4 tally was 351-450 cells per microlitre.
The paper says these figures shift the pendulum in favor of starting treatment earlier, especially as new antiretrovirals have fewer side effects than before.
"In view of diminished concerns about toxic effects and resistance, our results suggest that 350 cells per microlitre should be the minimum threshold at which antiretroviral therapy is started," it says.
In a comment also published in the Lancet, South African AIDS specialists Robin Wood and Stephen Lawn cautioned against the one-size-fits-all recommendation, however.
Poor countries often have a limited range of HAART drugs available and must make tough decisions about cost effectiveness, they say.
Last August, a panel of American doctors in the International AIDS Society (IAS) also spoke in favor of raising the threshold to 350 CD4 cells per microliter or higher.
The benefits from controlling HIV earlier include lower incidence of lung, anal, head and neck cancers, cardiovascular disease and kidney and liver dysfunction, they say.
(Agencies via China Daily April 15, 2009)
