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HAART Treatment for HIV: Less May Be More

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Nov. 27, 2001 -- Hit hard and hit early was the mantra when highly active antiretroviral therapy (HAART) was introduced for treating HIV infection six years ago. But concerns over serious treatment side effects have led many clinicians to delay therapy for people without the symptoms of AIDS, and federal health officials endorsed this wait-and-watch approach in guidelines released early this year.

Now, two landmark studies suggest that treatment can be safely delayed even longer than the government guidelines suggest. And experts say the findings may have a dramatic impact on when HIV therapy is initiated.

Writing in the Nov. 28 issue of TheJournal of the American Medical Association, researchers from the University of British Columbia report that most people with the AIDS virus may be able to safely delay treatment until the level of CD4 immune cells (the cells destroyed by the virus) in their blood falls below 200 per cubic milliliter. In a separate study, researchers in the United Kingdom concluded that low numbers of these immune system cells and high amounts of virus in the blood (viral load) at treatment initiation were not associated with poor response to antiretroviral therapy in a large group of patients.

Delaying HIV therapy would lessen the chances that patients would develop a range of side severe effects from their medications, including nerve damage, weakened bones, high cholesterol, heart disease, and diabetes.

"There are still unanswered questions with regard to treatment, but there is much more clarity that there was, with the publication of these two studies," HIV clinician and researcher Roger J. Pomerantz, MD, tells WebMD. "Instead of treating everyone hard and early, as we did early on, it is now clear that we should treat everyone hard but at an appropriate time. That doesn't always mean early."

Pomerantz, who wrote an editorial evaluating the two studies, says he was in the aggressive, early treatment camp until seeing them. The February release of government guidelines urging delay of HAART treatment until immune system cells were very low -- CD4 counts were less than 350 -- or the viral load was more than 50,000 did not persuade him to be less aggressive. Chief of infectious diseases at Philadelphia's Thomas Jefferson University, Pomerantz has treated AIDS patients for almost 20 years.

"Even though I come from this very aggressive treatment group, I feel very comfortable having written this editorial," he says. "It appears that, with a few caveats, people who are treated when their CD4 counts approach 200 have a median length of survival and mortality that is no different from those treated earlier. This finding would have startled people five or six years ago."

The new findings may convince doctors to delay HAART therapy in many infected patients, but there still may be subgroups who benefit from early treatment regardless of CD4 count or viral load. Several studies suggest that people whose HIV infections are identified within six months of seroconversion can retain near normal immune systems if treatment is begun immediately.

Pomerantz estimates that just 2% of HIV patients are identified this early, adding that it is not yet clear whether delaying treatment would be feasible in this group or in patients who experience dramatic drops in CD4 counts over a short period of time.

"These are patients that need to be watched closely," he says. "And there may be others who benefit from earlier treatment."

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