Starting HIV Drugs Earlier May Delay AIDS But Not Death

New research suggests that HIV-infected patients are most likely to stay clear of AIDS longer if they start drug therapy when their immune systems are still relatively strong. However, starting treatment earlier, compared to waiting, didn't affect dying from AIDS. "There wasn't a clear benefit in terms of preventing death" by prescribing the drugs before some guidelines suggest, said Dr. Keith Henry, director of HIV clinical research at Hennepin County Medical Center in Minneapolis and co-author of a commentary accompanying the study, published in the April 19 edition of Annals of Internal Medicine.

The issue of when to begin drug treatment is a hot topic in the field of AIDS/HIV medicine. If physicians wait to begin treatment, patients can delay the expense not to mention the side effects of pricey anti-HIV drugs. But such delays may also give the virus a chance to become more powerful and better able to fend off medications. If they're not treated with drugs, HIV-infected people almost always go on to develop AIDS. So when should doctors turn to the drugs? In the U.S., guidelines suggest that HIV-infected patients take them when the level of CD4 cells an important part of the immune system dips below 0.500 X 109 cells per liter (cells/L).

In Europe, the guideline number is frequently lower meaning a weaker immune system at under 0.350 X 109 cells/L.In the new study, researchers examined how patients did when they began drug therapy with their CD4 cells at a variety of levels. The study authors examined the medical records of almost 21,000 HIV-infected patients who sought treatment in HIV clinics in Europe and through the Veterans Health Administration system in the United States. The researchers found that the death rate was about the same regardless of whether patients began treatment when their CD4 levels dipped under 0.500 X 109 cells/L or if they waited until their immune systems deteriorated more and reached below the level of 0.350 X 109 cells/L.

Gene Therapy Against HIV Not a Proven Cure

Experts are reacting with cautious optimism to the announcement Monday that researchers reconfigured immune cells so that they became resistant to HIV in six patients infected with the virus. But they say the jury is out on whether the technique might ever spell an end to AIDS. The goal is ultimately a cure or what's called a "functional cure" having the body permanently keep HIV at bay but "we're not there yet," stressed Dr. Michael Kolber, professor of medicine and director of the Comprehensive AIDS Program at the University of Miami Miller School of Medicine.

The trial, reported Feb. 28 at a meeting of HIV specialists in Boston, "was a proof-of-principle that they could go in and do this. They demonstrated that the cells stayed in the patients, but the patients were not cured," said Kolber, who was not involved in the new research. Another expert agreed that the treatment's true potential remains uncertain. "If successful, this probably could have wide application, but going from six patients to an entire epidemic is a ways to go," said Dr. Michael Horberg, director of HIV/AIDS at Kaiser Permanente Health Plan and vice chair of the HIV Medicine Association.

"With other successes we've already had, that makes it more promising and people are starting to have a greater vision as to what's possible." However, as Kolber pointed out, this trial was what's known as a phase I trial, which means it was primarily looking at safety, not effectiveness, although investigators do often report on initial effectiveness results at this stage. The idea came from an isolated case that first made headlines in 2009, involving the so-called "Berlin patient." This man, an American AIDS patient living in Germany, was apparently cured after receiving blood cells from a donor who happened to have a rare, natural immunity to HIV.

More Older Americans Living With HIV

Better treatments are extending the lives of people with HIV, but aging with the AIDS-causing virus takes a toll that will challenge the health care system, a new report says. A survey of about 1,000 HIV-positive men and women ages 50 and older living in New York City found more than half had symptoms of depression, a much higher rate than others their age without HIV. And 91 percent also had other chronic medical conditions, such as arthritis (31 percent), hepatitis (31 percent), neuropathy (30 percent) and high blood pressure (27 percent). About 77 percent had two or more other conditions. About half had progressed to AIDS before they got the HIV diagnosis, the report found.

"The good news is antiretroviral therapies are working and people are living. If all goes well, they will have life expectancies similar to those without HIV," said Daniel Tietz, executive director of the AIDS Community Research Initiative of America. "But a 55-year-old with HIV tends to look like a 70-year-old without HIV in terms of the other conditions they need treatment for," he said Wednesday at a meeting of the Office of National AIDS Policy at the White House in Washington, D.C. The research included interviews with 640 men, 264 women and 10 transgender people. Dozens of experts on HIV and aging attended the meeting, which was intended to identify the needs of older adults with HIV and to explore ways to improve services to them.

Currently, about 27 percent of those with HIV are over 50. By 2015, more than half will be, said the report. Because of their special needs, this poses challenges for public health systems and organizations that serve seniors and people with HIV, Tietz said. HIV can be isolating, Tietz said. Seventy percent of older Americans with HIV live alone, more than twice the rate of others their age, while about 15 percent live with a partner, according to the report. The survey found that loneliness was higher among HIV-positive adults than for other older Americans. One reason is that many men and women conceal the condition from friends and family for fear of stigma or rejection, both real and imagined, Tietz said.