The WhiteCoats are coming! In the newest volley in the revolution against the "hit early, hit hard" rule, the British HIV Association (BHIVA) issued revised guidelines for when to start HAART that are decidedly more conservative than the "reverse course!" trumpeted by the U.S. in February. The Brits now recommend that symptom-free HIVers with CD4-cell counts from 200 to 350 (350 is the U.S. marker) take the cocktail only if their viral load is above 100,000 (30,000 in the U.S.) or their CD4 cells fall by more than 80 in one year.
This year's official retreat from early intervention on both sides of the pond is widely viewed as a case of catch-up with recent clinical practice, as more and more HIVers and their docs -- alarmed by HAART toxicities and viral resistance -- delay starting or take breaks from treatment. Yet the dearth of definitive "when to start" data -- there's still no large-scale clinical trial -- renders any recommendation questionable. Predictably, some Yankee researchers pooh-poohed the lower Brit numbers, pointing to stats showing a long-term survival benefit of earlier treatment. But BHIVA defends its "Patience, patients!" approach as the best way for HIVers signing on to lifelong HAART to minimize its curses -- side effects, adherence demands, drug resistance and failure -- while maximizing its blessings. Call it the British T (cell) Party.