Early treatment for HIV infection strengthens the immune system better than waiting, a new study suggests. Researchers looked at records for 468 adults with HIV infection. Levels of CD4 cells, a key part of the immune system, rose during the first 4 months of the estimated date of infection. Then they began to drop as the infection killed the cells. People started taking medicines, called antiretroviral therapy (ART), at different times. CD4 cell counts recovered in 64% of those who started ART within 4 months of infection and 34% of those who started later. The New England Journal of Medicine published the study. HealthDay News wrote about it January 16.

By Robert H. Shmerling, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

It's been nearly 30 years since human immunodeficiency virus (HIV) and the AIDS epidemic first appeared in the United States. People who had the infection then usually died within a few years. Often, they lived only a few months.

All that changed after the development of effective medicines. For those taking anti-retroviral therapy (ART) as prescribed, long-term survival has become the rule rather than the exception.

Yet, all these years later it is still unclear when ART should be started. Should it start as soon as HIV infection is detected? Should it wait until the number of CD4 cells, a key part of the immune system, drops below a certain level? Or should treatment begin at some point in between?

It might seem that starting ART right away would make the most sense. But early treatment may mean longer treatment. That could mean a greater risk of side effects and higher costs.

People starting ART also must be committed to keep taking their medicines. If not, early treatment may cause more harm than good. Starting and stopping treatment may increase the risk that the virus will resist the drugs.

Starting ART is clearly important for people who have a decrease in CD4 cells. They have an increased risk of serious infections and other health problems. Treatment is also important for an HIV-infected person whose sexual partner is not infected. That's because treatment can avoid spreading the infection. People who are pregnant or have certain medical conditions (such as hepatitis C) also benefit from early ART.

Two new studies in this week's edition of the New England Journal of Medicine examined the impact of starting ART therapy soon after HIV infection is diagnosed.

The first study found that CD4 counts increased to normal levels in:

• 64% of those receiving early ART (within 4 months of infection)
• 34% of those who started later

The second study found that starting ART within 6 months of infection and continuing it for 12 weeks was not as good as continuing it for 48 weeks. CD4 counts were low in:

• 61% of people who got the short course of treatment (similar to counts among those receiving no ART)
• 50% of those who got the longer course

Together, these studies suggest that earlier and longer lasting ART is better than later or shorter treatment. These studies are not the final word, though. They did not show fewer deaths, fewer infections or other benefits for those receiving early ART. However, measures of CD4 are among the standard indicators of how well treatment is working. So these findings could be important.

What Changes Can I Make Now?

If you are infected with HIV and are not taking ART, talk to your doctor about these new studies. Perhaps you and your doctor will decide that now is the time to start. Or you may decide to wait until the CD4 count is lower or the viral load (amount of virus in your blood) is higher.

The best approach to HIV infection, of course, is prevention. Researchers continue to work on a vaccine. But, even without a vaccine, HIV is a highly preventable infection.

Do what you can to avoid becoming infected with HIV. Here are steps you can take to reduce your risk:

• Avoid unprotected sex with an infected person. If you are sexually active, learn about safe sex and limit your number of sexual partners.
• Avoid transfusions unless absolutely necessary, especially if you’re in a place where the blood supply is not safe (such as some developing countries).
• If you use intravenous drugs, never share needles.
• If you are a health care professional, take precautions to avoid needle sticks or other exposures to body fluids.
• Seek medical care right away if you may have been exposed to HIV. Treatment right after an accidental needle stick or high-risk sex can reduce the chances you'll be infected.

Get tested for HIV and encourage your partner to be tested. Many people who have HIV do not know it. Testing is especially important if you're thinking of becoming pregnant. Treatment during pregnancy can dramatically reduce the chances of passing the virus along to your unborn child.

If you have already been infected with HIV, you can take medicines and other precautions to live a longer, healthier life and reduce the spread of the infection. See your doctor regularly and be sure you understand the treatment recommendations.

What Can I Expect Looking to the Future?

Future research may assess the impact of early ART on how long and how well people live with HIV, and the balance of costs and benefits. Until then, we will have to rely on studies such as these that look only at CD4 counts.

In places where ART is hard to obtain or not affordable, starting ART right after infection may not be an option. I hope that costs will fall in the future so that anyone infected with HIV can have the best treatment options.