Treatment Guidelines for HIV-Positive Adults Call for Delay in Therapy Initiation

Representatives of a panel of AIDS experts next week at the 8th Conference on Retroviruses and Opportunistic Infections will announce updated guidelines for the treatment of HIV-positive adults that call for delaying initiation of antiretroviral drug therapy, the AP/Contra Costa Times confirms, following several commentary pieces this week regarding the rumored changes. The guidelines, the result of a joint effort between HHS and the Henry J. Kaiser Family Foundation, are "still being fine-tuned," but recommend waiting to begin treatment until after patients' viral loads increase to 30,000 viral copies per milliliter of plasma as indicated on a branched DNA test, or 55,000 on a RT-PCR test, and their CD4+ T cell counts fall to 350 cells per cubic millimeter. The previous guidelines recommend beginning treatment when the viral load level reaches 10,000 viral copies per milliliter by branched DNA, or 20,000 copies by RT-PCR, and 500 CD4+ T cells per cubic millimeter (Recer, AP/Contra Costa Times, 1/31).

Hit Hard, Hit Later?
When AIDS researcher David Ho said five years ago that a new drug "cocktail" might "eliminate the virus [from] and potentially cure" patients who are HIV-positive, doctors, activists and pharmaceutical companies "jumped on the bandwagon" with a "hit early, hit hard" approach to treatment and began prescribing a combination of drugs to "relatively healthy" HIV-positive patients, ABCNews.com reports. The drugs were a "godsend" to patients living with HIV/AIDS, reducing AIDS-related deaths by almost 70% in the last five years. But now researchers say that the drugs' "promise has not lived up to the reality." Citing drug resistance and "dangerous" side effects -- such as high cholesterol, kidney failure, liver metabolism alterations and loss of nerve sensations -- the government has said that the problems "outweigh any benefits of treatment" and will recommend that "less ill" patients postpone such therapy until their counts meet the new guidelines. In 1996, researchers "had no data that hitting hard was either bad or good," David Barr, director of the Forum for Collaborative HIV Research, said. "The general approach to infectious diseases was that the sooner you get rid of them the better to eliminate infection," he added (Eisner, ABCNews.com, 1/31). The new guidelines have not changed for patients with symptoms of advanced HIV, or AIDS, including those with opportunistic infections (AP/Contra Costa Times, 1/31). Dr. Robert Schooley, head of infectious diseases at the University of Colorado Health Sciences Center, said that the revision of the recommendations "won't be the last time the pendulum swings in AIDS treatment," adding that the disease is a "constantly evolving target" (ABCNews.com, 1/31).

If You've Started, Don't Stop
Some researchers are worried that the new recommendations may "prompt an overreaction from both patients and doctors -- that patients will stop medication, even if they are doing well, or refuse to even start," the Los Angeles Times reports. Schooley said that some patients have heard of the change to the guidelines and, frightened by the potential side effects, have stopped taking their medications. He said that one of his patient's viral load count increased "more than a thousandfold" and T cell count fell to "less than half" of what it had been after she decided to stop taking her medications. "There's no question there are complications from these drugs, but I would rather deal with these side effects than dying," Schooley said. Fauci "stressed" that the change in the guidelines do not apply to patients who are already taking medications and doing well (Cimons, Los Angeles Times, 2/2).