New York Times Examines Timing of HIV Treatment Initiation
The New York Times on Thursday examined a New England Journal of Medicine study that found asymptomatic HIV-positive people who delayed antiretroviral treatment until their disease reached a more advanced stage faced higher mortality rates than those who initiated treatment earlier. While the study "is not the final word on the matter," it says that initiating treatment earlier than some current guidelines could reduce the risk of death. Similar findings were published online earlier this month in the journal Lancet, the Times reports.
For the NEJM study, researchers led by Mari Kitahata, director of clinical epidemiology at the Center for AIDS and Sexually Transmitted Diseases at the University of Washington, tracked survival rates for more than 17,500 asymptomatic North American HIV patients who received care from 1996 to 2005 in two separate observational studies. The first study compared patients who started antiretroviral therapy when their CD4 counts measured between 351 and 500 cells per cubic millimeter to those who deferred treatment until their CD4 levels fell below 350. It revealed that those who deferred treatment had a 69% increased risk of death compared to the early-treatment group. The second analysis compared patients with CD4 counts above 500, who started antiretroviral therapy within 6 months, to patients who postponed treatment. Those who deferred treatment had a 94% higher risk of death compared to the early-treatment group.
According to Kitahata, the study examined "one of the most important questions in the last decade: what the optimal timing is for starting therapy." She added that the recent research "provides evidence that patients would live longer if antiretroviral treatment was begun when their CD4 count was above 500" (Rabin, New York Times, 4/30).
Two related editorials also appeared in the April 30 edition of the NEJM. Summaries appear below.
- "When To Start Antiretroviral Therapy: Ready When You Are?:" Although the results of a Kitahata's study are "striking," they "cannot be considered definitive evidence that everyone with HIV should start receiving antiretroviral therapy," Paul Sax and Lindsey Baden of the Division of Infectious Disease at Brigham and Women's Hospital write. They continue that despite the researchers' "relatively large" sample size and use of "advanced statistical methods," their study was not a "randomized trial, and the patients who chose to begin therapy early might have differed in other important ways from those who chose to defer therapy - ways that improved survival but were not measured." Sax and Baden add that "a conclusion would require data from a randomized, prospective clinical trial, and at least three such studies are either ongoing or planned." They conclude that despite the study's "limitations," evidence supporting the benefits of earlier antiretroviral therapy "continues to increase, making strategies to identify patients with HIV infection before the onset of substantial immunodeficiency all the more compelling" (Sax/Baden, New England Journal of Medicine, 4/30).
- "Rationing Antiretroviral Therapy in Africa: Treating Too Few, Too Late:" Although the international health community has achieved "striking advances" in increasing access to antiretroviral treatment in Africa, "too few people are receiving treatment" and health workers "are waiting until people are symptomatic" before administering antiretroviral therapy, writes Nathan Ford - head of the medical unit of Doctors Without Borders in Cape Town, South Africa and research associate at the School of Public Health and Family Medicine at the University of Cape Town - with colleagues. They continue by writing that although "delaying therapy may mean saving money on drugs," the "long-term cost of such delays is increased substantially by the need for more intensive clinical care, decreased income, and likely regimen switches." In addition, later antiretroviral initiation "encourages the spread of tuberculosis" and could increase the risk of HIV transmission "by allowing patients to remain viremic longer," the authors write. They conclude, "The battle to start providing antiretroviral therapy in the developing world has been won. The battle to provide the best care we can is just beginning" (Ford et al., New England Journal of Medicine, 4/30).