Important note: Information in this article was accurate in 2009. The state of the art may have changed since the publication date.
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The New York Times - April 14, 2009
Donald G. Mcneil Jr.
Researchers have identified a new benchmark for starting drug treatment for AIDS, according to a report published online last week in the journal Lancet.
The question of when to start therapy has been a "swinging pendulum," notes an editorial accompanying the study. The marker in question is the CD4 count, which represents how many of the cells that the AIDS virus attacks are found in a microliter of blood.
In poor countries, the World Health Organization recommends starting when counts are anywhere from 200 to 350; in rich countries, the decision is made by patients and doctors. The new analysis, which looked at 18 studies with 45,000 American and European patients, concluded that starting earlier saved more lives, so treatment should begin when the count falls to 350.
It is a tradeoff. Aggressive early treatment may forestall full-blown AIDS and death, but antiretroviral drugs can cause fat redistribution, hepatitis, kidney failure, pain and elevated heart disease risk. Newer regimens are less toxic, but they are not always available in poor countries, where fewer than half of those who need drugs get them.
The finding has complex implications for Africa, where the number of people sick enough to need the drugs is increasing by about one million a year. If the W.H.O. adopts the new benchmark, the number could grow by another million, some estimate. Global donations to pay for treatment have not kept up with even today's needs.
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