JAMA editorial endorses later treatment

A further signal that US clinicians are being steered away from early treatment

of HIV infection came today with the publication of an editorial in the Journal

of the American Medical Association suggesting that recent data appear to

support postponing treatment until the CD4 T lymphocyte count approaches 200

cells.

The

editorial implicitly endorses revised British treatment guidelines published in

July 2001, which recommended that antiretroviral treatment should be delayed

until the CD4 cell count had fallen close to 200 cells, unless the CD4 cell

count was falling rapidly.

British HIV Association guidelines, and the JAMA editorial, were developed

in response to recent data showing no additional benefit to starting treatment

with a CD4 cell count above 350 (the previous UK threshold for starting

treatment). This threshold is still recommended in the United States as the

time to begin antiretroviral therapy.

However,

two studies published today in JAMA show that:

is no difference in rates of disease progression between people with CD4 cell

counts between 200-350, and above 350.

is no difference in response to therapy (defined as probability of viral

suppression below 500 copies) between people who start therapy with CD4 cell

counts between 200 and 349 cells, and people with CD4 cell counts of 350 or

above.

These

studies are discussed in more detail in When to start treatment on tbis

website. 

These

studies do not answer the question of when is the optimum time to start

treatment.

An

editorial in the November issue of AIDS Treatment Update, NAM’s

treatment newsletter, questions whether it is ethical to delay any longer the

development of a large randomized study that can answer the “when to start

treatment” question.

"In

the middle of the 1990s…plans for a large, international trial called Tempo

were drawn up. Tempo, which would compare immediate versus deferred

combination therapy, never got off the ground. There’s been no further plan for

this kind of when-to-start strategy trial since, in part due to practical

barriers such as the likely low clinical event rate, but also because the view –

not least from HIV treatment advocates – that such a trial would be unethical,

has been voiced so loudly. In comparison, few have questioned the ethics of not

doing a trial of this kind.”