HIV therapy; when to start, what to take

At AIDS 2008, Dr Anton Pozniak of London’s Chelsea and Westminster Hospital asked the two most central questions anyone starting therapy needs to consider “when to start?” and “what to start with?"

The move to start treatment earlier is gaining momentum in light of evidence that those untreated patients with CD4 counts above 350 have significantly higher rates of non-AIDS related illnesses such as cardiovascular disease. Pozniak stated that clinical trials are needed to weigh the benefits of starting earlier with the downsides of earlier therapy, including toxicity, resistance and maintaining long-term adherence.

With regard what to start with, Pozniak discussed the results of the first randomised clinical trial to compare the use of boosted protease inhibitors (PI) with non-nucleoside reverse transcriptase inhibitors (NNRTI) which found virological and immunological benefits to both approaches. Pozniak reviewed data on monotherapy (one drug therapy) with boosted PIs, which may save money and spare users the long-term toxicity of nucleoside reverse transcriptase inhibitors (NRTIs).

He also noted some unexpected toxicities associated with regimens using NRTIs as the backbone of treatment.  Some nucleosides (such as d4T) are used extensively in resource-poor countries despite these toxicities, because of lower costs. Pozniak also presented evidence of the effectiveness of tailored combinations for treatment-experienced patients. He concluded that in situations where there is a choice of therapies, treatment of HIV has become focused on minimising side effects and maximising convenience, and that this choice should be offered to all people living with HIV.