New York City pushes earlier treatment for AIDS

In an effort to halt the spread of AIDS, health officials in New York City recommended yesterday that treatment with anti-AIDS drugs should begin as soon as an individual is diagnosed with the human immunodeficiency virus (HIV), the virus that causes AIDS, rather than waiting for it to begin harming the immune system.

New York City Health Commissioner Dr. Thomas Farley sees the switch as a new way to fight the disease. As he told the Wall Street Journal, “I’m more optimistic now than I’ve ever been about this epidemic that we can drive our new rates down to zero or close to it—eventually.”

As my Harvard Health colleague Peter Wehrwein described in a post on Worlds AIDS Day 2011, drug therapy can help prevent the transmission of HIV. Using it earlier may help protect the immune system.

HIV destroys the type of infection-fighting white blood cells known as CD4 cells. As the number of CD4 cells dwindle, the body becomes more susceptible to infections. These are often infections that people with healthy immune systems fight off easily.

Healthy people have CD4 counts that range from 500 to 1,500 cells per cubic millimeter of blood. Current guidelines for treating HIV say that anyone with a CD4 count below 350 should start treatment with an HIV-fighting antiretroviral drug. The guidelines also suggest that doctors don’t have to wait until the count falls that low, and recommend a CD4 count below 500 as a useful “trigger.”

Some AIDS experts question the value of waiting until CD4 counts begin to dip, and recommend—as New York City officials have done—starting anti-HIV therapy as soon as the virus is detected. These drugs can’t totally rid the body of the virus. But they can keep the number of HIV particles low enough to slow down, and perhaps even prevent, destruction of the immune system.

Some cautions

This “early start” approach is based on promising preliminary data. It’s possible that larger, longer studies will support it. It’s also possible that they would raise red flags. Other cautions from AIDS experts include:

• Anti-HIV drugs are expensive.
• If a person doesn’t take these drugs on schedule, the virus can become resistant to them.
• Anti-HIV drugs often have negative side effects, and can increase the risk of developing diabetes, heart and blood vessel diseases, and other chronic conditions.

What I’ll be telling my patients

Given what we know today, I plan to encourage my HIV-infected patients to start anti-HIV therapy sooner rather than later. Beginning therapy before CD4 counts fall below 500 may—and unfortunately I must stress the “may”—keep the immune system stronger for longer. In addition, early treatment lessens the likelihood of passing HIV to someone else. Today, this is the strongest argument for starting anti-viral therapy right away.

Early treatment is especially important for people with a high number of HIV particles in the bloodstream (called the viral load). A higher viral load increases the chances of a more rapid decline in immune function. It is also a good choice for people who aren’t comfortable waiting to treat a medical problem that could be treated now. For them, early treatment could be an important psychologic boost.

Early treatment may not be the best option for people who aren’t good about taking medications and those with a family history of diabetes or heart disease.

Cost is certain to be an issue, but there are a number of programs available to help people pay for these drugs.

As with so many situations in medicine today, the decision to start anti-HIV treatment early—before CD4 counts decline—is a personal one. If you have been infected with HIV, or are worried that you might be, talk with your doctor about testing and the best step forward.

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