According to the results of a study published in Clinical JournalInfectious Diseases,delaying the start of treatmentantiretroviral could have serious consequences for people living with HIV in middle age or older. The survey found that peoplebetween ages 45 and 65 years begun antiretroviral therapy with low cell countsCD4- 350 200 or cells / mm3- had higher mortality ratethose observed in patients who started treatment with CD4 cell count of about 500 cells / mm3.
The scientific evidence that has been generated in recent years has led to the consolidation of the tendency to recommend earlier initiation of antiretroviral therapy (seeLa Noticia del Día 02 / 06 / 2015). Thus, they formed the AIDS Study Group (GeSIDA) and the National Plan to combat AIDS (PNS) in 2015 updating its consensus document with regard to antiretroviral therapy in adults with HIV. In accordance with current guidelines,It recommended to start antiretroviral therapy for all patients with HIV infection regardless of their levels of CD4. The force and the gradation of recommendation varies according to different conditions and circumstances. The recommendations highlight Spanish - in line with the rest of international guidelines - that early treatment not only provides a benefit to the patient's health, but may have important implications for public health.
It is known that age is a risk factor for poorer health outcomes in people with HIV who are not receiving treatment and diseases associated with aging are increasingly important causes of death in patients receiving antiretroviral therapy (seeLa Noticia del Día 01 / 07 / 2015). However, this time, is not at all clear whether there is an association between having an older age and getting worse clinical outcomes when it delayed the initiation of antiretroviral therapy.
In order to shed more light on this issue, a group of researchers of the integrated network of clinical systems research centers on AIDS in the United States (CNICS / LFT), analyzed the mortality rates for ten years according to age and CD4 cell count at the time of initiation of antiretroviral therapy in 3.532 people with HIV.
The analyzed patients began to receive expert assistance between 1998 and 2013 and all had a CD4 cell count at the start of about 500 cells / mm3. Mortality rates were compared according to CD4 count when starting treatment: not less than 500 cells / mm3; 350 cells / mm3; and 200 cells / mm3. Moreover, comparisons were made for each threshold of CD4 cells according to the patient's age at the onset of treatment: the 18 34 years 35 the 44 years 45 and 65 the years.
Most patients (82%) were male; a third, black ethnicity; and 67% were gay and other men who have sex with other men (MSM). The median CD4 cell count at the time of study entry was 646 cells / mm3.
The researchers found a mortality rate in ten years of 13% (n = 165). As expectedIt was observed a relationship between the CD4 count at the beginning of treatment and mortality rates, and initiate treatmentwith a cell count greater than or equal to CD4 500 cells / mm3 was associated with lower mortality rate (11%); increased mortality 12% in patients who delayed starting treatment until CD4 count be 350 cells / mm3 and increased up to 14% in patients who started treatment with CD4 cell count 200 cells / mm3 .
With regard to age, patients withaged 45 and 65 years had the highest mortality rates for any CD4 cell count limit.Start CD4 therapy with a threshold of at least 500 cells / mm3 was associated with a ten-year mortality 19%; the rate increased to 22% in patients that delayed the start of treatment to achieve the limit of 350 cells / mm3; andincreased to 28% in those who received the therapy when their CD4 cell count was located in 200 cells / mm3.
The impact of delaying the initiation of antiretroviral treatment CD4 until the cell count reaches the limit of 350 cells in younger patients (18 24 to years) in terms of mortality was not obvious. In this sense, the researchers point out: "Our results suggest that in younger patients who are beginning to receive specialized care for HIV with high counts of CD4, could be less urgent initiation of antiretroviral therapy in terms of health outcomes at the individual level "; and added: "These findings help provide new evidence framework for benefits describe the variables at the individual level to the beginning of the treatment very immediately according to age."
However, with regard to elderly, middle-aged, the results are clear. "The dramatic increase in mortality in ten years, when the initiation of antiretroviral therapy in people with HIV infection over 45 years is delayed demonstrated the great importance of starting treatment early in the infection in this group of patients," the researchers concluded .
Bearing in mindthat in Spain the year 2013, 21,9% of new HIV diagnostics occurred in persons over 45 yearsit is essential to strengthen national efforts to ensure, in this segment of the population, prevention, detection, connecting with the specialized care as well as early treatment and maintenance in the health care system.
Source:Aidsmap / Elaboración propia (gTt-VIH)
Reference:Edwards JK et al. Age at entry into care, timing of antiretroviral therapy initiation, and 10-year mortality Among HIV-seropositive adults in the United States. Clin Infect Dis, online edition, 2015.