Starting HIV treatment

There is a lot of debate about the best time to start HIV treatment and some doctors think there would be advantages to starting treatment earlier, if someone is diagnosed with a higher CD4 count. A big international study called START is underway to try to establish if there are advantages to starting HIV treatment earlier than is currently recommended.

The advantages of earlier treatment may include a reduced risk of HIV-related illnesses and non-HIV-related illnesses, such as cardiovascular disease and some cancers. In addition, early treatment may be a way of controlling the epidemic, as successful therapy significantly reduces potential infectiousness.

But earlier treatment would have cost implications and healthcare budgets around the world, including the UK, are under considerable pressure.

Untreated HIV is known to cause inflammation, something which can increase the risk of serious illnesses, but there is not much information on the effect this has on someone with a high CD4 count.

To investigate this, European researchers looked at the medical records of approximately 11,500 people.

They divided people into groups according to the level of their viral load. Most people (82%) had a low viral load (below 500 copies/ml); 11% had an intermediate viral load, between 500 and 10,000 copies/ml, and 9% had a high viral load, defined as being above 10,000 copies/ml.

Their research showed that people who had a high or intermediate viral load were much more likely than those with a low viral load to develop a serious HIV-related illness, even when their CD4 cell count was above 350.

There was also some evidence that having a viral load above 500 copies/ml was associated with an increased risk of developing a non-HIV-related illness such as cardiovascular disease.

To put this risk in context, based on the results of this large study around two people in every hundred with a high viral load could be expected to develop a serious HIV-related illness every year, compared with around one in every 200 people with a low viral load.

Another recent European study showed that if treatment guidelines were changed to recommend that people start HIV treatment when their CD4 cell count is around 500, it would mean that 50% of HIV-positive people would need to start treatment within a year of their infection with HIV.

This compares to about a quarter of people needing to start therapy within twelve months if the CD4 threshold was 350.