More scrutiny for early ART
The warning came after the United States treatment guidelines (updated in December last year) recommended that patients be started on treatment when their CD4 counts (measure of their immunity) fall below 500.
Current World Health Organisation guidelines recommend for ART initiation at CD4 counts less than 350.
The activist group including the Treatment Action Campaign, INSIGHT Community Advisory Board and HIV i-Base said there was currently no data on the advantages and risks of initiation at 500.
They said the Start study that was currently enrolling patients would investigate whether there was evidence to support the US recommendation. They said their statement affirmed the importance of both the START trial as well as the safety of those who enrol.
‘We believe that the priority for HIV-positive people is to have accurate, reliable data on both the risks and benefits of earlier treatment in order to base any decision for when to start treatment,’ they said.
The organisations’ joint statement:
When to start antiretroviral treatment is one of the most important outstanding questions for people with HIV and their clinicians. A large clinical trial, Strategic Timing of Antiretroviral Treatment (START), has begun and will hopefully help answer this and other important questions. [1]
The START trial includes antiretroviral-naive HIV-positive people with CD4 counts greater than 500 cells/mm3. It is taking place at about 90 sites in nearly 30 countries. Participants are randomised to either receive antiretroviral treatment immediately or to defer treatment until their first CD4 count less than 350 cells/mm3 or they have clinical signs of AIDS. Eventually, START will recruit 4,000 people.
The deferred arm is the current standard of care throughout the world, with guidelines recommending treatment at a CD4 count of 350 cells/mm3. Clinical trials have demonstrated that once the CD4 count drops to below 350 cells/mm3, antiretroviral treatment should begin. [2, 3] However, the recent US guideline change requires a community response for US patients who still want to take part in this study.
On 1 December 2009, the United States (US) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents were changed to recommend treatment for patients with CD4 counts between 350 and 500 cells/mm3. Of the more than two-thirds of Panel members who supported this recommendation, 55% recommended it strongly and 45% moderately. As explained in the guidelines, this recommendation is based solely on observational data primarily from two large cohorts known as ART CC and NA-ACCORD. As with all observational data the findings from these cohorts could be subject to confounding factors. [4]
Indeed, the ART CC investigators have stated, ‘We are concerned that some may interpret the new recommendations as implying that the deferral group of this trial is no longer ethical. Such an interpretation would endanger the future of the trial in the .’ [5]
They further state, ‘We ‘¦ do not believe that there is convincing evidence to conclude that deferral of initiation of ART to a CD4 count of [350 cells/mm3] causes net harm, particularly in terms of mortality, compared with starting at any higher level. We strongly support continued enrolment into START. Large randomised studies represent the only means of eventually obtaining the definitive result we need to properly inform future patient care.
We agree with the ART CC investigators. The available evidence is insufficient to determine if the adherence challenges and long-term side-effects of early antiretroviral treatment are outweighed by reduced risk of illness conferred by these medicines. Only a randomised controlled trial, such as START, can determine this.
The NA-ACCORD data is also challenged by the researchers who orginally developed the new statistical methodology. They were not convinced that the application thereof was without problems. [6]
We too are concerned that the new US recommendation:
(1) raises theoretical concerns about continued enrolment of patients in the US, a substantial source of patients, and
(2) is based on poor evidence and therefore might not be in the best interests of patients.
We also have further concerns that:
(3) previous recommendations to use earlier treatment failed to recognise the negative impact of resistance and side effects, and
(4) a minority of individuals have normal CD4 counts between 350-500 and would therefore be using treatment prior to any significant immune damage.
We support research findings that the absolute risk of HIV-related complications remains very low at a CD4 count 350’500 and that individuals enrolled in START will be carefully monitored and access treatment if their health circumstances change.
We also support the unique importance of sub-studies in START.
These studies have the potential to answer important questions relating to the impact of HIV, treatment and ageing on neurology and mental health, bone health, heart disease, lung disease and behaviour risk.
We support the START investigators, community advocates and HIV-positive people interested in this dynamic research which will help close the essential gap in our current knowledge on the safety and risks of earlier treatment.
Author
Health-e News is South Africa's dedicated health news service and home to OurHealth citizen journalism. Follow us on Twitter @HealtheNews
Republish this article
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Unless otherwise noted, you can republish our articles for free under a Creative Commons license. Here’s what you need to know:
You have to credit Health-e News. In the byline, we prefer “Author Name, Publication.” At the top of the text of your story, include a line that reads: “This story was originally published by Health-e News.” You must link the word “Health-e News” to the original URL of the story.
You must include all of the links from our story, including our newsletter sign up link.
If you use canonical metadata, please use the Health-e News URL. For more information about canonical metadata, click here.
You can’t edit our material, except to reflect relative changes in time, location and editorial style. (For example, “yesterday” can be changed to “last week”)
You have no rights to sell, license, syndicate, or otherwise represent yourself as the authorized owner of our material to any third parties. This means that you cannot actively publish or submit our work for syndication to third party platforms or apps like Apple News or Google News. Health-e News understands that publishers cannot fully control when certain third parties automatically summarise or crawl content from publishers’ own sites.
You can’t republish our material wholesale, or automatically; you need to select stories to be republished individually.
If you share republished stories on social media, we’d appreciate being tagged in your posts. You can find us on Twitter @HealthENews, Instagram @healthenews, and Facebook Health-e News Service.
You can grab HTML code for our stories easily. Click on the Creative Commons logo on our stories. You’ll find it with the other share buttons.
If you have any other questions, contact info@health-e.org.za.
More scrutiny for early ART
by Health-e News, Health-e News
May 12, 2010