New HIV Guidelines Will Advise Delayed Treatment
Jan. 30, 2001 -- Marked changes in HIV treatment guidelines, scheduled for release in early February at a meeting of AIDS experts, reflect dashed hopes that the current drugs can ever cure HIV infection -- and a sobering appreciation of the drugs' adverse effects over time.
For instance, new guidelines for how women with HIV infection can use the drugs during pregnancy -- both to maintain their own health and to keep from spreading the infection to their newborn children -- have vastly expanded sections on drug side effects.
Most striking, however, are the anticipated changes in guidelines for treating adults and teenagers with HIV infection. Only a few years ago, most experts recommended the "hit early and hit hard" approach -- starting treatment as soon as possible with the most powerful anti-HIV drugs. But the new guidelines will advise postponing treatment until there are unmistakable signs of approaching AIDS.
"I think it is a reflection of the 'death of the cure' paradigm," Michael Saag, MD, tells WebMD. "The whole rationale behind 'treat hard, treat early' was based on assumptions that anti-HIV therapy alone could lead to eradication of the virus in three or four years. More recent data indicate that it probably would take 15 or 20 or even 60 years of complete suppression of virus to achieve a cure. When combined with the unfortunate development of drug-related toxicities ... all this [makes] everyone rethink when we should begin therapy." A pioneer in clinical trials of AIDS drugs, Saag directs the AIDS outpatient clinic at the University of Alabama at Birmingham.
Another AIDS research pioneer -- Stephen Spector, MD, of the University of California at San Diego -- sits on the advisory panels that developed the perinatal and adult/adolescent HIV treatment guidelines for the U.S. Public Health Service. "I don't think it is the death of hope," he tells WebMD. "What I do think is that it is a reality check in which we are taking a step back and saying we are not going to eradicate the virus.
"So much has changed with HIV -- it is no longer the automatic death sentence it once was," Spector explains. "It is now a chronic illness. So the question is, 'How can you use the medications to keep people well for as long as possible?'"
Saag stresses that immediate, potent anti-HIV treatment is extremely important for people very recently infected with HIV. For these individuals, early treatment can be so effective that they stand a good chance of eventually being able to stop taking AIDS drugs.
Most people, however, do not find out that they have been infected with HIV until several months have gone by. By then, they have chronic HIV infection, and it is better to postpone therapy.
The new guidelines recommend waiting until T-cell counts -- a measure of how much damage HIV has done to the immune system -- drop to 350 cells/mcL (healthy people have T-cell counts of about 1,000 cells/mcL). Symptoms of AIDS usually occur after T-cell counts drop below 200 cells/mcL.
Spector emphasizes that while the new guidelines for pregnant women have a lot of new information about drug side effects, successful HIV therapy keeps a woman healthy throughout her pregnancy and prevents her baby from getting the AIDS virus.
"[M]ost of the toxicities being talked about -- particularly serious ones -- are very uncommon," Spector tells WebMD. "For the vast majority of HIV-infected women, the interventions are extremely safe. The benefits far outweigh the risks."