New draft guidelines issued this week by the British HIV Association recommend that antiretroviral treatment may be delayed until it is clear that an individual's CD4 count is heading fast towards 200 cells/mm3, the level at which AIDS-defining illnesses may develop.
Individuals with high viral load (above 100,000 copies/ml) or a fast declining CD4 cell count (more than 80 cells per year) may be recommended to start treatment while their CD4 cell count lies between 200 and 350 cells/mm3, but no one with a CD4 cell count above 350 will be encouraged to start treatment. This is because experts are concerned about long-term drug toxicity, and the risk of accumulating drug resistance if treatment fails after an early start.
The British recommendations follow the presentation of studies at two recent international conferences which show that the virological response to treatment does not differ in people with CD4 cell counts between 200 and 500, provided that their viral load is below 100,000 copies. It also follows the presentation of several cohort reviews which show no difference in the rate of progression to AIDS between those with CD4 counts above 350 and those between 350 and 200.
US treatment guidelines were recently amended to fall into line with the longstanding British recommendation that treatment should start around the 350 CD4 cells level.
To view the updated guidelines or comment on the guidelines, click here.