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Push for early HAART treatment
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Leigh Dayton and Adam Cresswell | July 24, 2007
note from Jules: In this article Fauci is quoted as saying clinical trials are necessary before treating earlier. There are many pluses and minuses when considering a "when to start HAART study" including that the landscape of therapy will change in 2 years where integrase and CCR5 drugs are expected to be increasingly used. When patients are on drugs that donŐt cause lipid elevations how then do you compare that group in terms of cardiovascular risk to a patient group starting HAART now who begin with ART drugs that lead to abnormal lipid profiles. The question of whether to conduct a large expensive trial has been a contentious debate.
STARTING HIV-AIDS patients on powerful anti-retroviral drugs earlier than is now the case could keep people healthier longer.
"A lot of new evidence is indicating we need to seriously re-examine the issue," says Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the US National Institutes of Health in Bethesda, Maryland.
Guidelines for HIV treatment generally recommend delaying the use of "triple therapy" drugs until the virus is proved to be damaging a patient's immune system. The idea is to reduce the toxic side effects of long-term use of the medication, which must usually be taken for life.
But Dr Fauci, a leading HIV-AIDS researcher, told The Australian yesterday that scientists were looking at two lines of evidence suggesting side effects such as organ damage were caused more by the virus than the drugs.
Dr Fauci is in Australia as a keynote speaker of the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, held this week in Sydney.
Dr Fauci said the first wake-up call came last year as findings emerged from the 33-nation Strategic Management of Antiretroviral Therapy trial.
According to Dr Fauci, who chaired a discussion on early treatment, the SMART trial results fit with studies of groups of children infected with HIV.
"Those children who were treated very early, on discovery they were infected, versus waiting until evidence of immune system decline, it was unquestionable that the children who were treated early did better," he said. But he cautioned that earlier treatment must be supported by clinical trials.
Conference delegates heard yesterday that experts now had a better understanding of how HIV undermines the body's defences, and that this might lead to new avenues of research.
In one of three opening addresses, Michael Lederman, director of the Centre for AIDS Research at Case Western Reserve University in Ohio, said HIV's role in destroying immune cells lining the gut was now thought to play a bigger role than previously thought in accelerating the immune system's decline.
The destruction of CD4 killer T-cells lining the gut meant that fragments of microbes normally contained within the digestive tract leaked into the bloodstream, where they could activate sleeping immune cells and boost HIV replication.
"We think the downstream consequences of that are quite deleterious," Professor Lederman told The Australian.
"In my opinion, this could open up new targets for intervention in HIV."
Another opening speaker doused claims that the war on AIDS was about to be won. Brian Gazzard, director of HIV research at London's Chelsea Westminster Hospital, said claims that "we're on the cusp of dramatic development and we're going to beat AIDS would be a disaster - one, because it's untrue, and two, because it sends the very wrong message".
His comments were in response to remarks by Michel Kazatchkine, executive director of the Global Fund, who was reported as saying new drugs meant AIDS was no longer a death sentence.
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