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We now know that, in a cruel paradox, HIV actually became more virulent in patients who did a pretty solid (but not perfect) job of taking their pills on time than in patients who did a very poor job of taking their meds.
Moreover, physicians began to observe in their patients health problems that were caused by treatment toxicities. Researchers also found that patients who fail on early treatment regimens may close future treatment options that would have remained open if they had not burned through certain medicines prematurely. Finally, a three-country study recently revealed that, for almost all patients, starting treatment within three years of infection yields no additional benefit whatsoever.
A couple of qualifiers: remember that day of diagnosis is not the same as day of infection. If you were likely infected years ago, but just diagnosed today, your timeline begins at the time of infection. Also, treatment might depend on your condition and your symptoms.
What’s new?
Does the new study overturn these hard learned lessons? Is earlier treatment always better? Dr. Kenneth Lichtenstein’s study, released at CROI, did find that patients who waited too long to initiate treatment harmed themselves in two ways.
Lichtenstein looked over records of 2,304 patients studied between 1996 and 2005. Compared to late starters, earlier treaters were more likely to bring their virus down to undetectable levels in the bloodstream. They were also 60% less likely to develop kidney insufficiency, 30% less likely to report peripheral neuropathy, and 60% less likely to develop lipoatrophy (loss of body fat, particularly troublesome in the face).
The study’s authors acknowledged that the earlier treaters may have been more proactive about their health maintenance in many ways, so some of the benefits they enjoyed may have resulted from their faithfully taking their medicines every day.
But all this study really demonstrates is that starting treatment during the recommended period is better than waiting until past that period. To determine when treatment is really needed, your physician looks primarily to two numbers: viral load (the amount of virus in your bloodstream) and CD4s (the amount of an important part of your immune system that is still intact). Ideally, the first number should be low, and the second number high.
As recently as 1997, United States Health and Human Services guidelines recommended an aggressive approach, initiating treatment for patients with even moderate viral load (20,000 copies/ml) and a hearty immune system (up to 500 CD4s). In successive years, the guidelines pushed treatment initiation out further and further, now suggesting treatment begins when viral load is over 100,000 and/or when CD4s drop below 350 (with symptoms) or near to 200 regardless of symptoms.
Though people living with HIV differ widely in their disease progression, these current guidelines would allow the average infected individual to postpone treatment for up to eight years following infection, merely monitoring his/her progress through bi-annual blood work ups.
The late starters in Lichtenstein’s study were too late to reap the greatest benefits from treatment according to HHS guidelines. So it’s no surprise that they fared worse. This does not mean that someone starting even earlier than recommended would do better still.
“Hit Early, Hit Hard” remains a discredited strategy. Perhaps the new slogan should be “Hit HIV Hard When the Time is Right.” Call it the Goldilocks approach: not too early, not too late, but just right to live longer and healthier with the virus.
Stephen Fallon is the President of Skills4, Inc., a healthcare and disease-prevention consulting firm that specializes HIV prevention and management. Visit his website at www.skills4.org. If you need sources for any medical information cited in his columns, e-mail him at sfallon@skills4.org.
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