When to initiate antiretroviral
therapy remains a controversial issue, but recent data suggest that starting
with a higher CD4 cell count - perhaps even above the currently recommended cut-off
of 350 cells/mm3 - may lead to better long-term outcomes.
As reported in
the February 1, 2008 Journal of Acquired Immune Deficiency Syndromes, Spanish
researchers analyzed factors associated with progression to AIDS or death in HIV-infected
patients in the Proyecto para la Informatización del Seguimiento Clínico
epidemiológico de los pacientes con Infección por VIH/SIDA (PISCIS)
cohort. Based on this, they calculated the optimal time to initiate HAART,
taking lead time into account.
The analysis included 2035 treatment-naive
patients without an AIDS diagnosis at baseline who started HAART after January
1998. The median follow-up period was 34 months. Statistical analyses were performed
using Cox proportional hazards models. Lead time was defined as the time it took
the deferred treatment group with an early-stage disease to progress to the later
stage.
Results
•
Multivariate analysis showed significantly higher
hazard ratios (HRs) for disease progression in patients with:
•
Individuals who started HAART between January 2001
and June 2004 had a decreased risk of progression (HR 0.55).
•
After accounting for lead time and unseen events,
the researchers observed a higher risk of disease progression among patients who
deferred treatment until their CD4 count fell below 200 cells/mm3 compared with
those who started in the 200-350 cells/ mm3 range (HR 2.97).
•
Further, patients who started treatment within the
200-350 cells/mm3 range had a higher risk compared with those who started treatment
with > 350 cells/mm3 (HR 1.85).
Conclusion
"Advanced
HIV disease, HCV coinfection, and early HAART period were determinants of AIDS
progression or death," the study authors concluded. "Lead-time analysis
in asymptomatic HIV-infected patients suggests that the best time to start HAART
is before the CD4 count falls to lower than 350 cells/[mm3]".
3/21/08
Reference A
Jaen, A Esteve, JM Miro, and others. Determinants of HIV progression and assessment
of the optimal time to initiate highly active antiretroviral therapy: PISCIS Cohort
(Spain). Journal of Acquired Immune Deficiency Syndromes 47(2): 212-220.
February 1, 2008.
Results
