AIDS experts in the US are about to complete a humiliating U-turn when the
Department of Health and Human Services launches its revised HIV treatment
guidelines in January.
The revisions will underline the need to hold back from using powerful
antiviral drugs until the immune systems of HIV patients show significant signs
of decline. It reflects the view, long held by British doctors, that early use
of currently available drugs may do more harm than good.
Charles Carpenter, associate director of the Brown University AIDS programme,
told a Royal Society of Medicine meeting in London last week: “In retrospect, we
now realise the risk of drug toxicity is greatly enhanced by taking these drugs
.”
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For the past four years, leading American physicians have led the “hit hard,
hit early” campaign which encouraged patients to take cocktails of powerful
antiviral drugs in the early stages of the disease in the hope of preventing
damage to the immune system.
British doctors were often ridiculed at conferences and in the pages of
research journals for suggesting the drugs be used more cautiously, in case they
proved too toxic for patients who take them for years or decades at a time.
Carpenter is in charge of producing the US version of the International AIDS
Society treatment guidelines. They have just fallen into line with British HIV
Association guidelines which recommend that patients should not get triple
therapy until their “CD4 count”—the number of T-helper immune
cells—falls to less that 350 per millilitre of blood. The normal level is
around 800 per millilitre.
“This shows that for us all medicine is a very humbling process,”Carpenter
told the audience of US and British AIDS experts.
“It’s wonderful to see how after a long period you’ve moved closer to us,”
replied Ian Weller, head of clinical HIV research at University College London.
“The hit hard and early crowd are now hitting hard but later.”
Weller, who is also deputy chairman of the Medical Research Council’s HIV
Therapeutics Trials Committee, has long voiced fears that taking a combination
of protease inhibitor and transcriptase inhibitor drugs early on in HIV disease
could do patients more harm than good.
In January, the other major source of guidance for American doctors treating
people with HIV, the DHHS/National Institutes for Health, will publish their own
revised guidelines. 91av has learned these will also adopt the
more cautious approach favoured by British experts.
Anthony Fauci, head of the NIH’s AIDS research division programme, has
publicly stated that doctors have underestimated how difficult it is to stick to
the treatments.
Anti-HIV drugs have been linked to a disfiguring redistribution of body fat,
liver disease and damage to mitochondria, as well as less specific ailments such
as nausea and tiredness. The drugs also have to be taken in complex combinations
every day.
“It does reduce the quality of life for several years,” said Carpenter. But
both doctors noted that the drugs have been successful in extending the lives of
people with AIDS.
Nonetheless, Weller added that the start of treatment might have to be
delayed even further, as new side effects emerge. He noted that the vast
majority of serious AIDS-related infections occurred in people with CD4 counts
less than 200.
The speakers agreed that early treatment might be justified in people who had
only just become infected. In such people, there was still the possibility of
protecting a special class of T cells that are destroyed very early in
infection.
