AN international team of researchers claimed that patients who start HIV treatment when their CD4 cell count is around 500 are less likely to develop an AIDS-defining illness than patients who start therapy at lower CD4 cell counts.Controversy has trailed the best time to initiate HIV treatment. While the current European and British guidelines recommend that therapy should be started when a patient has a CD4 cell count of around 350, United States S guidelines say that treatment should be started when a patients CD4 cell count is in the region of 500, and they dont rule out starting treatment earlier.Large randomised trials are currently underway to try and determine the optimum time to start HIV therapy. However, their results are not expected for several years.Because of this continuing uncertainty, an international team of investigators from the HIV-CAUSAL Collaboration undertook a prospective observational study involving approximately 21,000 adult patients enrolled in cohorts in Europe and the U.S.They reported in the recent edition of the journal of Annals of Internal Medicine that patients who start antiretroviral therapy when their CD4 cell count dipped below 500 cells/mm3 are less likely to develop an AIDS-defining illness than individuals who start treatment with a CD4 cell count of 350 cells/mm3.However, they noted that initiating HIV treatment with a CD4 cell count of approximately 500 cells/mm3 did not reduce the risk of all-cause mortality.If the goal is to prevent AIDS-defining illness or death, our findings support cART (combination antiretroviral therapy) initiation once the CD4 cell count decreases below 500 cells/mm3, they stated.The latest study involved 21,000 patients in Europe and the U.S., who received care between 1996 and 2009. All had a baseline CD4 cell count above 500.Indeed the results of their study showed that patients who waited to start HIV therapy until their CD4 cell count fell below 350 were 38 per cent more likely to develop AIDS than patients who started treatment when their CD4 cell count was around 500.The risk of all cause mortality and the risk of AIDS-related illness or death was compared between patients who started HIV treatment when their CD4 cell count was 500 cells/mm3 or above; between 350-499 cells/mm3; 200-349 cells/mm3; and below 200 cells/mm3.A total of 390 patients developed an AIDS-defining illness or died before their CD4 cell count fell below 500 cells/mm3. HIV therapy was started by 2893 patients when their CD4 cell count was above 500 cells/mm3, and 9296 maintained a CD4 cell count above this level without the need for treatment.The remaining 8292 patients experienced a fall in their CD4 cell count to below 500 cells/mm3 after a median of nine months.However, there was no evidence that starting treatment at 500 was associated with better overall survivalrates were similarly high for patients who started therapy at 350.Non-HIV-related diseases such as heart, kidney and liver disease are now an important cause of serious illness in patients with HIV. Doctors think that starting treatment earlier will reduce the risk of these illnesses.Importantly, the investigators did not gather information on the impact of earlier treatment on the risk of serious, but non-fatal, non-AIDS related illnesses.The authors of an accompanying editorial suggest that the results of the study should be treated with caution, and that doctors should have frank conversations with their patients about what we do and what we dont know about starting cART.Nevertheless, results of the study will undoubtedly inform the debate about the best time to start antiretroviral therapy.
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