Art Chimes | St. Louis, Missouri 21 July 2010

 
Photo: AP/Mikhail Metzel
A new study shows beginning AIDS treatment earlier can save lives.

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Fitzgerald article on early HIV treatment (NEJM)

A new study of HIV-infected people in Haiti indicates that starting treatment early could save many patients who might otherwise die of AIDS. And starting anti-AIDS medicines earlier might also save money.

The World Health Organization currently recommends that patients begin taking AIDS medicines, called antiretroviral drugs, when symptoms appear or when their CD4 count drops below 200.

The count measures immune cells that are killed off by the AIDS virus, HIV.

Beginning treatment when CD4 drops to 200 works well, but a team of Haitian and American doctors at the GHESKIO clinic in Port-au-Prince wanted to see if they could do better.

In the study, patients were randomly assigned either to get AIDS medicines when their CD4 count hit 200, the standard procedure, or to get the antiretrovirals earlier, when their CD4 had only dropped to 350.

Researcher Daniel Fitzgerald explains that "the results of the trial showed that the rate of mortality was cut by 75 percent if antiretroviral drugs were started earlier. And also that the rates of tuberculosis" — a common side-effect of HIV infection — "that those rates were cut in half by starting earlier."

Fitzgerald says his randomized study provides additional support for previous studies that suggested doctors are sometimes waiting too long before beginning treatment for HIV-infected patients.

"I think there have been some observational, smaller studies that suggested the same thing. So when you put these observational studies together with a 'gold standard' clinical trial, the findings are overwhelming."

The new standard of starting treatment at a CD4 count of 350 has already been embraced by the World Health Organization and the United Nations' UNAIDS program. The new treatment protocols come as the 18th International AIDS Conference is set to open in Vienna, July 18-23.

The study was conducted in Haiti, one of the world's poorest countries, with one of the highest rates of HIV infection outside Africa. Antiretroviral drugs have come down in price, but starting treatment earlier can still represent a lot of money. Nevertheless, Fitzgerald says it looks like a good investment.

"My strong belief is that it may in the long run save more money, that we're preventing a lot of tuberculosis," he says. "We're preventing people from going into the hospital. We're making people who would have been feeling sick and maybe not being able to work as much — are able to keep their jobs. So I think the tradeoffs are enough that it's really worth it to start early."

We reached Daniel Fitzgerald at his office at Weill Cornell Medical College in New York. The paper on early HIV treatment is published in the New England Journal of Medicine.