Sunday, November 30, 2014

Early Timing of Antiretroviral Therapy Associated With Immune Restoration

Digital Representation of The HIV Virion
A report published online by JAMA Internal Medicine suggests that early initiation of antiretroviral therapy (commonly referred to as ART) is correlated not only with decreased viral load, but also with immune recovery and reduced AIDS risk. The best results were seen when ART was begun within 12 months of seroconversion, which means the point at which antibodies against a pathogen are detectable in the blood. The researchers defined immune recovery as CD4+ T-cell counts in infected patients that were comparable to uninfected individuals.

After measuring the CD4+ T-cell counts of healthy individuals, researchers identified ≥900 cells/microliter as the normalized cell count, and they predicted that patients that achieved counts closer to this value would have (1) a greater T-cell response to chemical messengers that maintain immunological homeostasis (2) a decreased risk for developing AIDS and (3) lowered T-cell over-activation, which can exacerbate disease.

Data for the study was obtained retrospectively from the US Military HIV Natural History Study, an observational study of military men and women and their partners, and it supported the researchers’ hypothesis.

To provide context, ART given to patients with HIV-1 infection tends to be administered with the sole purpose of diminishing viral load. In the past, this objective has been acceptable, for viral load is correlated with poor recovery. Now, however, researchers acknowledge that decreasing HIV-1 viral load is achievable when antiretroviral therapy is prescribed and taken successfully. Thus, clinical attention is changing, focusing more on restoring the immune system of immunocompromised individuals in addition to decreasing viral load.

The report provides strong evidence to support initiatives for early testing and improved drug access. In the United States, the wholesale cost of antiretroviral therapy can range from $300 to over $3000 per month.1 Infected individuals can receive help in obtaining treatment from Medicaid, Medicare, The Ryan White Program, and the AIDS Drug Assistance Program,2 but these programs have income requirements that may still exclude individuals that need help obtaining care.

If the best results for immune restoration occur if ART is administered within 12 months of seroconversion, it is imperative that infected individuals become aware of their HIV status early, so they can begin drug therapy sooner rather than later. Moreover, drugs must be affordable and available—knowing that you’re HIV positive is far less tolerable if you don’t have access to treatment.

We need studies like this to provide (almost self-evident) support for public health campaigns that can improve health outcomes when they provide appropriate interventions. More importantly, it’s important to acknowledge that this research underscores the inequities that exist in the United States’ health care system.

Access to treatment and testing is limited in impoverished communities of low socioeconomic status—a stark contrast to the military men and woman involved in the study detailed above, all of whom have access to free or subsidized and routine medical care. In fact, the incidence of HIV continues to be higher among low-income communities in the United States.3

As research and treatments become more sophisticated, our delivery systems must follow suit. Admittedly, sustainable sources of funding have to be identified and secured if treatment for HIV is to become even more widely accessible, but to fail to do so—and do so in earnest—is to concede defeat in the struggle against health disparities in the United States.

-Luis Garcia

1.     Cost of ART: 
2.     Programs that help pay for drugs:
3.     CDC Reports on Poverty and HIV Incidence:
4.     The JAMA Report:
5.     Graphic Link:


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