About AIDS
By Sandy Bartlett, Fri., July 26, 2002
New Guidelines: Perhaps HIV Drugs Can Be Delayed
New treatment guidelines suggest that HIV-infected people can wait longer than previously recommended to begin taking the anti-HIV drugs, if they are symptom-free. The new recommendations were announced at the International AIDS Conference in Barcelona two weeks ago.
This column often advocates that people with risk activity should get tested and, if HIV-infected, get into care at once. Getting "into care," however, does not necessarily mean starting the HIV medications. They are toxic (especially in the long-term), expensive, and a major hassle. Therefore, starting the drugs is postponed until a intolerable level of immune system damage has occurred (as measured by T4/CD4 cell count), or virus level has climbed unacceptably, or symptoms have developed. For several years, the recommendation had been to start medications if CD4 counts fell to 350/ml. of blood (typical CD4 count varies a lot, but it ranges around 1,000 for a healthy person).
Now, the International AIDS Society has concluded that drug treatment can be postponed until CD4 levels drop to between 200 and 350/ml. They acknowledge that some patients might benefit at higher CD4 counts, but generally, the drawbacks outweigh the benefits. They don't recommend specific drugs, but they note that patients are more likely to stick with regimens requiring pills taken only twice daily, rather than those drugs that must be taken more often, so that somewhat narrows the field for a treatment newbie.
Today, promptly getting care that adheres to the regimen are the keys to survival with HIV disease. This latest shift is not a dramatic one, but it puts off slightly the day when the pills have to become a major part -- indeed, a dictating part -- of a person's life. It's a good step forward.
(For details, see Journal of the American Medical Association, 2002; 288:222-235.)
