Current US guidelines advise that antiretroviral therapy for asymptomatic HIV patients should definitely be started for those who have CD4(+) cell counts of >200 cells/ microL, but antiretroviral therapy is often not started at CD4(+) cell counts much above that level. Guidelines advocating later therapy for HIV infection have been based mainly on sparse and limited cross-sectional data and have been predicated on avoiding drug-related toxicity and viral drug resistance. However, emerging data about factors that contribute to survival and the availability of newer, less toxic drugs are eroding this position. Earlier initiation of antiretroviral therapy--namely, for patients with CD4(+) cell counts of >350 cells/ microL--may, in fact, be associated with lower mortality, better immune improvement, and less drug-related toxicity. These findings coincide with the introduction of antiretroviral drugs that have become more effective and less difficult to take. Earlier initiation of therapy may also reduce HIV transmission, an important public health consideration, and may be beneficial in terms of overall therapeutic cost-effectiveness. Given these accumulating data, we believe reconsideration of the "when-to-start" question is timely and justified.
"In the past decade in developed countries, highly active antiretroviral therapies have dramatically decreased HIV infection morbidity and mortality [1-3]. When HIV care is initiated early, patient’s life expectancy becomes closer to that of the general population [4,5]. More recently, compelling evidence has demonstrated benefits of early treatment of HIV-infected patients for the global population by reducing HIV transmissions [6,7]. "
[Show abstract][Hide abstract] ABSTRACT: Background
In France, 1/3 HIV-infected patients is diagnosed at an advanced stage of the disease. We describe missed opportunities for earlier HIV testing in newly-HIV-diagnosed patients.
Cross sectional study. Adults living in France for ≥1 year, diagnosed with HIV-infection ≤6 months earlier, were included from 06/2009 to 10/2010. We collected information on patient characteristics at diagnosis, history of HIV testing, contacts with healthcare settings, and occurrence of HIV-related events 3 years prior to HIV diagnosis. During these 3 years, we assessed whether or not HIV testing had been proposed by the healthcare provider upon first contact in patients notifying that they were MSM or had HIV-related conditions.
1,008 newly HIV-diagnosed patients (mean age: 39 years; male: 79%; MSM: 53%; diagnosed with an AIDS-defining event: 16%). During the 3-year period prior to HIV diagnosis, 99% of participants had frequented a healthcare setting and 89% had seen a general practitioner at least once a year. During a contact with a healthcare setting, 91/191 MSM (48%) with no HIV-related conditions, said being MSM; 50 of these (55%) did not have any HIV test proposal. Only 21% (41/191) of overall MSM who visited a healthcare provider received a test proposal. Likewise, 299/364 patients (82%) who sought care for s had a missed opportunity for HIV testing.
Under current screening policies, missed opportunities for HIV testing remain unacceptably high. This argues in favor of improving risk assessment, and HIV-related conditions recognition in all healthcare facilities.
"However, despite considerable advances in HIV treatments, there is still debate about the optimal way to use them. The best time to start a patient on HAART is an open question (Ahdieh-Grant et al. 2003, Cohen and Boyle 2004, Harrington and Carpenter 2000, Ho 1995, Hoffman and Mulcahy 2007, Holmberg et al. 2004, Jeffrey et al. 2003, Lepri et al. 2001, Mauskopf et al. 2005, O'Shaughnessy et al. 2000, Phillips et al. 2003, Schackman et al. 2002a, Tebas et al. 2001). According to Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, the question of when to initiate therapy is " the most important question in HIV therapy " (Hoffman and Mulcahy 2007, p. 176). "
[Show abstract][Hide abstract] ABSTRACT: The question of when to initiate HIV treatment is considered the most important question in HIV care today. Beneflts of delaying therapy include avoiding the negative side efiects and toxicities associated with the drugs, delaying selective pressures that induce the development of resistant strains of the virus, and preserving a limited number of treatment options. On the other hand, the risks of delayed therapy include the possibility of irreversible damage to the immune system, development of AIDS-related complications, and death. We use Markov decision processes to develop the flrst HIV optimization models that aim to maximize the expected lifetime or quality-adjusted lifetime of a patient. We prove conditions that establish structural properties of the optimal solution and compare them to our data and results. Model solutions, based on clinical data, support a strategy of treating HIV earlier in its course as opposed to recent trends toward treating it later.
Operations Research 02/2008; 56(1):20-33. DOI:10.1287/opre.1070.0480 · 1.74 Impact Factor
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