May 19, 2009

Study Authors Say Treat HIV and OIs at Same Time

Beginning HIV treatment right away in people who are diagnosed with HIV only after coming down with an opportunistic infection (OI)—rather than waiting until the OI treatment takes effect—may reduce early disease progression or deaths without increasing treatment complications, according to a study published in the online journal PLoS One and reported by ScienceDaily.

Deciding when to initiate antiretroviral (ARV) therapy in people who are diagnosed with HIV and an OI at the same time has been a contentious subject. In one camp arere researchers who advocated for starting ARV treatment right away in order to boost the immune systems of people with HIV and reduce the direct harm of multiplying virus. In the other camp are more cautious researchers who fear that the many possible drug interactions and overlapping side effects could unnecessarily complicate treating the OI. Besides, they argue, treating the OI first usually means a delay in starting ARV therapy by several weeks at most.

To determine the benefits and risks of starting ARV right away, Andrew Zolopa, MD, from Stanford University in Palo Alto, California, and his colleagues randomized 282 recently diagnosed individuals to either begin ARV therapy within two weeks of starting OI therapy, or defer ARV therapy until the acute management of the OI had been completed. The study, titled AIDS Clinical Trials Group (ACTG) study A5164, looked for three potential outcomes in the two groups during a 48 week period: death or disease progression; no disease progression, but incomplete HIV suppression; or no disease progression and complete HIV suppression. Of the OIs diagnosed at study entry, 63 percent had Pneumocystis jirovecii pneumonia (PCP), 12 percent had cryptococcal meningitis, and 12 percent had other bacterial infections.

Zolopa and his colleagues found a distinct trend toward better outcomes in people who started ARV treatment early compared with those who deferred it. Only 14 percent of people who started treatment right away had disease progression or death, compared with 24 percent in people who deferred treatment. However, the size of the groups ultimately analyzed, 123 in each of the two arms, was too small to show a statistically significant difference. This means that the difference was small enough as to have occurred by chance. Contrary to what some researchers had feared, however, people who started ARV treatment early were no more likely to experience treatment complications or increased rates of side effects than people who deferred therapy.

Ultimately, the authors recommend that unless providers expect significant treatment complications, ARV therapy and OI treatment should begin simultaneously in newly diagnosed individuals who have OIs. “A lot of doctors wait [to start ARV therapy], thinking, ‘Let’s get the patient out of acute crisis, and then we’ll deal with [the underlying HIV infection] later,’” Zolopa said. “But that answer is wrong. If we’re more aggressive with HIV drugs, we can reduce AIDS-related complications…. It’s a substantial patient benefit.”

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