Hitting the AIDS virus with drugs before it breaches a widely-recommended threshold of damage to the immune system can carry major benefits for patients, a top panel said here on Sunday. Their guidelines were published at the start of a six-day world-wide conference gathering more than 20,000 scientists, policymakers and grassroots workers.
At present, under recommendations honed after antiretroviral drugs were introduced 12 years ago, doctors are generally advised to put a patient on the famous triple "cocktail" after HIV has made significant inroads into the immune system.
The threshold varies, but the typical recommendation is to start drugs when there are fewer than 200 to 250 CD4 cells-key immune cells that are ravaged by the virus-per millilitre of blood. The reason for this advice is to minimise the drugs' toxic side effects and to gain time. The recommendations were introduced when there was a major problem of treatment failure and doctors had only a tiny number of pharmacological weapons to choose from.
But the paper issued in Mexico City said these guidelines should be overhauled, as better, less toxic drugs are now available and the arsenal has expanded.
Its authors-a US panel of the International AIDS Society (IAS) - says there is mounting evidence for raising the threshold to 350 CD4 cells per millilitre or higher.
The benefits from controlling HIV earlier include lower incidence of lung, anal, head and neck cancers, cardiovascular disease and kidney and liver dysfunction, they said, pointing to data from several trials in the past two years.
"As treatment options have increased and the risks of untreated viremia [viral infection] are better appreciated, the risk-benefit ratio is shifting toward early treatment," according to the paper, published by the Journal of the American Medical Association (JAMA).
The updated recommendations also give a boost for using recently-approved drugs, including raltegravir, maraviroc and etravirine, in combination with older treatments to keep down viral levels and boost CD4 counts.
The new guidelines are intended for rich countries and "selected" middle-income countries where good diagnostic infrastructure and multiple drug options make it relatively easy for doctors to treat people with the human immunodeficiency virus (HIV). Today, there are now more than 30 individual drugs and fixed-dose combinations to treat infections.
Hampered by funds, poorer countries though have a far smaller range of treatment options and lack laboratory backup to see if a patient is responding to drugs.
The report said the "core principles" of the new guidelines were also applicable to developing economies, provided ways were found to make treatment and patient-monitoring simpler and cheaper. "Progress with antiretroviral rollout in the developing world is encouraging, but recent advances in the highly-resourced world need to be adapted and translated to the developing world to realise these benefits," the paper cautioned.
The IAS is hosting the International AIDS Conference, an event that takes place every two years. More than 25 million people have died from AIDS since the disease first emerged in 1981, and 33 million now have the AIDS virus, according to UN figures.