EMBARGO DATE CORRECTION — JULY not August — Study suggests earlier HIV antiviral treatment saves lives and is cost effective, even in areas of limited resources
Early initiation of lifesaving
antiretroviral therapies should be the standard of care for all HIV-infected patients, even those in countries with limited medical and financial
resources, according to a study led by Harvard Medical School (HMS) researchers
at Massachusetts General Hospital (MGH) and
the Desmond Tutu HIV Centre, University of Cape Town, South Africa.
The team reports in the Aug. 4 Annals of Internal Medicine that
starting antiretroviral therapy (ART) when the
level of CD4 T cells drops below a threshold of 350 per microliter of blood,
compared with below 250, would prevent nearly 76,000 deaths and avert 66,000
opportunistic infections over the next five years at an estimated cost of $1,200
per year of life saved. The study’s publication coincides with the International
AIDS Society Conference meeting which started yesterday in Cape Town.
The study provides strong support for broadening the eligibility standards for ART in settings
with sufficient access to drugs, the authors note. In the U.S. and other
developed countries, ART is usually initiated when the CD4 count – a measure of
immune system function – drops below 350. Recognizing that ART is both costly
and can have significant side effects, the 2006 World Health Organization (WHO) treatment
guidelines suggest waiting until CD4 counts drop below 200 or until patients
develop AIDS-related complications.
“While those standards accommodate the limited
resources and short supply of medications in many settings, the greater
prevalence of tuberculosis and other opportunistic infections in places like
South Africa argue for earlier treatment initiation,
even before the results of ongoing clinical trials are known,” says study leader Rochelle Walensky of the MGH Division of
Infectious Disease and associate professor of medicine at HMS.
Definitive clinical trial findings will not be
available for several years. Yet in countries like South Africa, which currently
has the world’s highest burden of HIV infection, information is needed today to
guide treatment policies and practices. To address this need, Walensky and
colleagues developed a mathematical model to simulate HIV treatment and its
associated health and economic outcomes. The model calculated the additional
costs of earlier treatment, its potential toxicities and its benefits, including
TB prevention. It also calculated how much delaying ART would shorten patients
lives and then estimated the cost per extra year of life gained – a standard
measure of cost-effectiveness – of earlier ART initiation.
“The time has come to act on the information we
now have, nearly all of which supports starting treatment earlier. We can
re-evaluate the situation after the trials, but until those results are
available, the evidence points to saving lives with earlier treatment,” says
co-author Robin Wood, director of the Desmond Tutu HIV
Centre at the Institute of Infectious Diseases and Molecular Medicine,
University of Cape Town. The center is a leading HIV clinical research group in South Africa
Additional co-authors of the report are Lindsey Wolf, Mariam Fofana, and Kenneth
Freedberg of MGH; Elena Losina of Brigham and Women’s Hospital; Neil
Martinson of the WITS Health Consortium, Johannesburg, South Africa; A.
David Paltiel of Yale University; Xavier Anglaret of the University of
Bordeaux, France; and Milton Weinstein of the Harvard School of Public Health.
The study was supported by grants from the National Institute for Allergy and
Infectious Diseases and the Doris Duke Charitable Foundation.