1. Home>
2. Specialties>
3. General Medicine>
4. Summary and Comment

When to Start HIV Treatment: A Work in Progress

The effectiveness of combination antiretroviral therapy no longer is in doubt, but the best way to use it still is debated. Current U.S. guidelines advise that HIV-infected patients begin treatment when CD4 counts drop below 350 cells/mm³ or plasma HIV RNA levels exceed 30,000 copies/mL, but many experts disagree with these recommendations. Results from 2 studies now suggest that treatment can be withheld safely until later stages of disease.

European researchers analyzed the outcome of 3-drug treatment in more than 3000 treatment-naive patients. Patients with pretreatment CD4 counts <200 cells/mm³ reached target viral loads more slowly and less reliably than did those with higher counts, but there was no difference between those with counts of 200-349 cells/mm³ and those with counts 350 cells/mm³. Patients with pretreatment viral loads 100,000 copies/mL had a slower rate of viral load reduction than did other patients, but those with viral loads <10,000 copies/mL and those with viral loads of 10,000-99,999 copies/mL responded similarly. Rates of viral-load rebound were equivalent among all pretreatment CD4 strata.

Canadian investigators looked at mortality in a cohort of 1219 treatment-naive patients who began 3-drug therapy. Survival after 36 months was significantly lower among those with pretreatment CD4 counts <200 cells/mm³ than among those with higher counts; it was even lower among those with pretreatment counts <50 cells/mm³. However, survival was similar for all pretreatment CD4 strata 200 cells/mm³. Pretreatment viral load did not influence survival.

Comment: It is important to avoid unnecessary use of antiretroviral drugs, which come with considerable cumulative toxicity. An editorialist confirms that, despite some methodologic difficulties in these studies, the results appear to support delaying treatment in many patients until CD4 counts approach 200 cells/mm³.

— Abigail Zuger, MD

Published in Journal Watch General Medicine December 11, 2001

Citation(s):

Phillips AN et al. HIV viral load response to antiretroviral therapy according to the baseline CD4 cell count and viral load. JAMA 2001 Nov 28 286 2560-2567.

• Original article (Subscription may be required)
• Medline abstract (Free)

Hogg RS et al. Rates of disease progression by baseline CD4 cell count and viral load after initiating triple-drug therapy. JAMA 2001 Nov 28 286 2568-2577.

• Original article (Subscription may be required)
• Medline abstract (Free)

Pomerantz RJ. Initiating antiretroviral therapy during HIV infection: Confusion and clarity. JAMA 2001 Nov 28 286 2597-2599.

• Original article (Subscription may be required)
• Medline abstract (Free)