Study Says To Start HIV Drugs Early
Share: 
2 April 2009 | 11 Comments
A new study in The New England Journal of Medicine says starting HIV meds early reduces your chance of death. People who started their meds when their CD4+ count was in the range 351 to 500 had a death rate of 1.6 deaths per 100 person years while people who started their meds when their CD4+ count was over 500 had a death rate of 1.3 deaths per 100 person years. Since it’s from the New England Journal of Medicine I’ll assume all of their assumptions are reasonable and the research methodology is as good as it gets.
When you read some of the articles that discuss the findings of the study it’s really a balance between drug toxicity over decades and staying alive.
“It must still be recognized that the long-term side effects of the anti-HIV drugs we now use are unknown, and could alter this recommendation after longer patient follow-up,” said Dr. Jeffrey Laurence, a professor of medicine at Weill Cornell Medical College in New York City.
That I think is the one possible weakness in the study – they studied people between 1996 and 2005 – so basically a decade’s worth of data. If a kid goes on the drugs at the age of 20 he’s got 60 years of taking drugs if he wants to live to 80. The study states:
Starting therapy at progressively higher CD4+ counts has been shown to lower the risk of some toxic effects associated with antiretroviral therapy, including peripheral neuropathy, anemia, and renal insufficiency. However, all the potential side effects of long-term antiretroviral therapy are unknown.
In other words, no one can tell you they know what the side effects of the drugs will be after taking them for 60 years…
While this study does give some strong evidence, it (combined with the other studies already done) leave some questions unanswered. In the end it’s a personal decision and everyone should do the research and make their own decisions… It’s your body and your life – you’re the only one that’s responsible for it.
Having a doctor that proposes a patient patient a vacation period is awesome for more than one reason. The toxicity of the HIV drugs has been unknown for years. Whether a person takes a break from it or starts an antiretroviral therapy at the lowest CD4+ point is “really” the patient’s choice.
Just have in consideration that virus load stays high for those not starting meds and it will go out of the “undetectable” status for those taking a vacation. Keep your bareback partner in the loop, MHO.
@rawTOP – Unfortunately they are not for everyone. I am not advocating the drug holiday here. If they work for the patient then it’s a beneficial way to stay away from the unknown long-term side effects of the drugs.
My point is if the patient can wait, while monitored by a doctor, to start an antiretroviral treatment the better in MHO. The death for other reasons for not starting treatment is, again in my opinion, less significant in the long run.
“The toxicity of the HIV drugs has been unknown for years.”
Problem is: So are the long term side effects of having a high viral load and low T-cells. You basically have to weigh two unknowns against each other.
On the one hand starting early with HAART usually means that your T-cells count returns to normal soon. But you have side effects -> metabolical toxicity.
Starting late means that you’re putting off these side effects, but being immuno-compromised for many years and the rebuilding of the immune system under HAART is also much slower, the lower the T-cell count you start with. These are years during which the seeds of cancer etc. can grow unchecked. Also we do not fully understand the long-term effects of high viral loads on the brain etc..
It’s like leaving your front door open to have an escape route in case of a fire – which leaves you vulnerable to other dangers.
But RawTop is right: It’s a case-by-case decision. A friend of mine had to go on meds a few months after being infected. Not because he wanted to start early, but because he simply had to. Every patient is different.
The figures of 1.6 vs. 1.3 deaths per 100 person-years are actually a bit misleading. These are the “crude rates of death,” that is, raw data that is reported before doing statistical adjustment for confounding variables and other biases. As you can see, the adjusted variables included “calendar year, cohort of patients, and demographic and clinical characteristics”, as stated in the abstract.
The more relevant and accurate statistic is the relative risk ratio, which was 1.69 (for those starting treatment with CD4 between 351 and 500 vs. deferring) and 1.94 (for those starting treatment with CD4 above 500 vs. deferring). In other words: if your CD4 count is between 351 and 500 now, you are 69% more likely to die if you wait than if you start treatment now. If your CD4 count is over 500, you are 94% more likely to die if you wait than if you start treatment now.
That is so not a significant difference. A simple chi-square test will tell you that.
Sorry, I’m a nerd.
We may not yet know the side effects of 60 of ART but we do know what 60 years of treatment does to the financial bottom line. $$$- cha-ching
@quriouscub73 – Not sure what you mean here. If you read the article (and as pointed out by rawtop), the differences were statistically significant. P < 0.001 for the 1.69 and the 1.94 relative risks. A relative risk of 1.94 is nearly a doubling of risk and you don’t even need that big of a sample size to detect that.