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Author Topic: AIDS patients with serious illness benefit from early anti-viral treatment  (Read 1272 times)

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Offline madbrain

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http://www.mercurynews.com/breakingnews/ci_12381683




Sick HIV-infected patients who get immediate anti-viral treatment are at far lower risk of dying than patients who go untreated longer, according to a major new Stanford University School of Medicine study.

Experts say the finding could lead to widespread changes in strategy for treating HIV patients, particularly those diagnosed at an advanced stage.

A review of care provided at 40 different sites found that 14 percent of patients who were treated promptly died or developed another infection during the year-long study. Of those whose treatment was deferred an average of 45 days, 24 percent died or sickened.

Despite a decade of effective medicines, no one has solved the puzzle: When should treatment start? The answer is clear in the case of many diseases, but not for infection with the AIDS virus — even when people are suffering from pneumonia or other opportunistic infections.

Many people with HIV — particular minorities, youth, injection drug users and those living in rural areas —do not know they are infected until they get sick with diseases like pneumonia. The virus causes few problems and almost no symptoms for years after it is acquired.

And once treatment starts, there are new challenges. Medicines are costly, have side effects like kidney failure and pain and must be taken for the rest of the patient's life. Many doctors fear anti-AIDS medicines will become resistant or interact with other
treatments.

Doctors often try to get patients through an acute crisis, then follow up later with treatment for HIV," said Andrew Zolopa, chief of Stanford's Division of Infectious Diseases and lead investigator of the study of 262 patients at 39 sites across the United States and 20 patients in South Africa.

"But that answer is wrong," he said. "The study shows very clearly that there is no safety downside to doing this — and the benefit is quite substantial, reducing death by 50 percent."

Between 60,000 to 70,000 newly HIV-infected individuals are identified every year in the United States. In Santa Clara County, about 1,882 people have been diagnosed with AIDS, and another 664 are infected with HIV but do not yet have symptoms, according to May 2008 data provided by the California Department of Public Health.

"This study started because the interns and residents at Stanford would admit an (HIV-infected) patient with pneumonia and they would start treating the pneumonia. Three or four days later, they'd call me and ask: When should we start anti-virals?" said Zolopa. "My answer was: 'I don't know.'"

These patients may not have routine access to medical care, said Zolopa. Perhaps they don't have medical insurance or have a drug problem. When rushed into a clinic for a crisis, physicians just seek to stabilize them, he said.

"Even in San Francisco, one of the first epicenters of HIV in the United States, we still find that many people present late in the course of their illness with an opportunistic infection," said Dr. Mitch Katz director of San Francisco's Department of Health, who was not involved in the study. "This study shows that it is life-saving to treat those persons with antiretroviral drugs while they are still in the hospital."

"The results of this study will change practices throughout the world," added Katz.

Treatment with HIV-fighting drugs improves the immune system, boosting patients' ability to resist further infections, according to Zolopa.

The Stanford findings, which were presented in abstract form at a scientific meeting earlier this year and will be published May 18 in the online journal PLoS-ONE, are already starting to change clinical practices. The International AIDS Society, the federal Centers for Disease Control and the British AIDS Society all have adopted guidelines that recommend early antiretrovial treatment be considered in patients with an opportunistic infection, Zolopa said.

A broader international study — to examine even earlier treatment — is under consideration by the National Institutes of Health. Enrolling more than 9,000 people, children and adults from poor and rich countries, that effort would compare treatment right after infection to treatment after the virus has already eroded the immune system. Participants would be followed and studied for five years to see who fares best.



Offline Ann

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Wow, seems like a no-brainer to me. If a patient is diagnosed with aids (in other words, diagnosed with a CD4 count under 200) and an OI, why wait to start ARVs?
Condoms are a girl's best friend

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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline Assurbanipal

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Wow, seems like a no-brainer to me. If a patient is diagnosed with aids (in other words, diagnosed with a CD4 count under 200) and an OI, why wait to start ARVs?

I don"t think it is quite so easy for a doctor faced with a patient in crisis.  There will likely be no genotype at hand, HAART may interact with the drugs being used to treat the crisis and the patient may be very weak and unable to withstand complications such as IRIS.   And all those issues play out within the hospital's protocols, which can lead to some subtle turf issues.

I was one of those patients.  I had pneumonia and was diagnosed by a lung specialist, so in the hospital I was his patient.  And as a lung specialist, given that there is no consensus on whether to start HAART, he was going to focus first on the pneumonia -- which was actively killing me.  He brought in an ID doc to consult; he did all the right things (and I am very grateful to him).  But his focus was on the pneumonia which was killing me right away and the drugs he was using for that came with hallucinations and other side effects.  Adding HAART drugs with significant potential side effects and interactions to deal with a long term condition would have meant taking additional risks with the treatment for the current problem.

That's why studies like this one are so important. They will help hard working doctors faced with making life or death decisions.

5/06 VL 1M+, CD4 22, 5% , pneumonia, thrush -- O2 support 2 months, 6/06 +Kaletra/Truvada
9/06 VL 3959 CD4 297 13.5% 12/06 VL <400 CD4 350 15.2% +Pravachol
2007 VL<400, 70, 50 CD4 408-729 16.0% -19.7%
2008 VL UD CD4 468 - 538 16.7% - 24.6% Osteoporosis 11/08 doubled Pravachol, +Calcium/D
02/09 VL 100 CD4 616 23.7% 03/09 VL 130 5/09 VL 100 CD4 540 28.4% +Actonel (osteoporosis) 7/09 VL 130
8/09  new regimen Isentress/Epzicom 9/09 VL UD CD4 621 32.7% 11/09 VL UD CD4 607 26.4% swap Isentress for Prezista/Norvir 12/09 (liver and muscle issues) VL 50
2010 VL UD CD4 573-680 26.1% - 30.9% 12/10 VL 20
2011 VL UD-20 CD4 568-673 24.7%-30.6%
2012 VL UD swap Prezista/Norvir for Reyataz drop statin CD4 768-828 26.7%-30.7%

Offline Ann

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Hi A,

Yes, I did think about the genotype consideration, but the study mentions patients who had to wait an average of 45 days - that's just over six weeks. A genotype can be done well before that. I also considered the probable weak state of the patient, but surely when PCP, for example, is being treated, the patient should be a bit stronger before six weeks. I've heard about cases like this in the past and I always thought it wasn't the best idea to defer treatment. I've also heard of cases where the decision to start ARVs was done almost immediately, pending genotype results, and in those cases it always seemed that the patient's recovery from the OI was much quicker.

But yes, apparent no-brainer or not, it's good that they're doing these studies so we have proof.

Ann
Condoms are a girl's best friend

Condom and Lube Info  



"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

 


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