The International AIDS Society will continue to recommend HIV treatment for asymptomatic individuals with CD4+ cell counts between 350 and 500 and viral load above 5,000 copies, in contrast to continued UK consensus that treatment is not warranted until the CD4+ cell count falls below 350 and viral load rises above 55,000 copies.
"Treatment effects on survival at higher CD4+ cell counts is not documented, and it is unlikely that such studies will be conducted", the authors comment.
Ironically, nearly 150 US researchers met on January 12 and 13 in Bethesda, Maryland to discuss setting up such a randomised study at the invitation of the US National Institute of Allergy and Infectious Diseases. Observational data from cohorts such as Eurosida already exists, and suggests no advantage to early treatment (see aidsmap news October 1999 or AIDS Treatment Update December 1999).
Both British and US clinicians agree that treatment is warranted for anyone with a CD4+ count below 350, regardless of viral load, and for anyone with symptomatic HIV disease.
Other significant differences between the IAS and BHIVA guidelines:
- A minimum viral load decline of 1.5-2 log should occur after 4 weeks on treatment, and viral load should be monitored monthly until it has fallen below 50 copies, according to the IAS guidelines. British guidelines are less explicit on this question.
- The IAS panel stress that any three drug regimen may be inadequate to suppress viral load below 50 copies in people with VL > 100,000 copies and CD4+ counts below 50. More aggressive therapy should be considered. British guidelines are also less explicit on this question.
- The IAS guideline are less confident in their recommendation of resistance testing than the BHIVA guidelines, noting only that "multiple drug therapy might be simplified by use of resistance testing to exclude less effective regimen components, but this has not been well evaluated".
Reference
Carpenter C et al. Antiretroviral therapy in adults: updated recommendations of the International AIDS Society-USA panel. Journal of the American Medical Association 283(2): 381-390, January 19 2000.