Six months after start of treatment could be optimum time for making prognosis in patients with HIV/AIDS

An international study in this week’s issue of THE LANCET suggests that prognosis for patients with HIV/AIDS might be more reliably determined six months after initiation of highly active antiretroviral therapy (HAART), rather than before the start of treatment.

HAART became widespread in more-developed countries from 1996 onwards, and has improved the prognosis of HIV-1 infection. However, not enough is known about how to predict the prognosis of people with HIV-1 infection starting HAART. The initial measurement of specific immune response cells (CD4 cells) and viral load at the time patients start HAART is related to HIV/AIDS progression; in general, the lower the CD4 cell count and higher the viral load, the worse the prognosis. As virus concentrations decline quickly in many patients, with substantial increases in CD4 cell counts within months of starting HAART, the accuracy of predictions of disease progression might be improved by accounting for initial response to therapy. This response might allow the early identification of patients who are at a high risk of progression and who might benefit from modification or intensification of therapy.

Matthias Egger from the University of Bern, Switzerland, and colleagues analysed 13 follow-up studies from Europe and North America, which included over 9000 patients receiving HAART (with a minimum of three drugs) for the first time. Overall, 152 patients died and 874 developed AIDS.

As expected, patients with higher CD4 counts had lower risks of AIDS or death six months after starting HAART than patients with low CD4 counts (for example, lower than 100 CD4 cells per millilitre); similarly, lower viral load was indicative of a better prognosis. Measurements of CD4 cells and viral load at the time of starting HAART were not, however, indicative of prognosis once the 6-month assessment had been taken into account.

Matthias Egger comments: “At 6 months after starting HAART, the current CD4 cell count and viral load, but not the values before the start of therapy, are strongly associated with subsequent disease progression. Our findings should inform guidelines on when to modify HAART in this group of patients who had not previously received antiretroviral therapy.”

Issue 30 August 2003