When the old account: Start treatment immediately could prove critical for people living with HIV aged above 45 years

old clock machineryAccording to the results of a study published in the journal Clinical Infectious diseases, delay the start of treatment antiretroviral could have serious consequences for people living with HIV in middle-aged or elderly people. The survey found that people between the ages of 45 and 65 years who started antiretroviral therapy with low cell counts CD4 - 350 or 200 cells / mm3 - showed higher mortality rate than those 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 early initiation of antiretroviral treatment (see La Noticia del Día 02 / 06 / 2015). Thus, they formed the AIDS Study Group (GeSIDA) and the National AIDS Action Plan (PNS) in 2015 to update their consensus document regarding 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.

croi-2015It 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 (see La Noticia del Día 01 / 07 / 2015). However, at this point, it is not at all clear whether there is an association between being older and achieving worse clinical results when the initiation of antiretroviral therapy was delayed.

Progress of lighting with candle, tungsten, fluorescent and LEDIn 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.

Group of diverse students outsideMost 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 entry into the study was 646 cells / mm3.

Researchers found a 10-year mortality rate of 13% (n = 165). As expectedIt was observed a relationship between the CD4 count at the beginning of treatment and mortality rates, and initiate treatment with a CD4 cell count greater than or equal to 500 cells / mm3 was associated with a lower mortality rate (11%); the increase in mortality of 12% in patients who delayed the start of treatment until CD4 count was of 350 cells / mm3 and increased by up to 14% in patients who began to receive treatment with CD4 cells count of 200 cells / mm3 .

With regard to age, patients with ages between 45 and 65 years had the highest mortality rates by any CD4 cell count limit. Initiating therapy with a CD4 threshold of at least 500 cells / mm3 was associated with a 10-year mortality of 19%; the rate increased to 22% in patients who delayed the start of treatment to reach the limit of 350 cells / mm3; and increased to 28% in those who received the therapy when their CD4 cell count was located in 200 cells / mm3.

HIV positive

The impact of delaying the onset of antiretroviral treatment until the CD4 cell count reaches the limit of 350 cells in younger patients (18 to 24 years) in terms of mortality was not so obvious. "Our results suggest that in younger patients who are beginning to receive specialized HIV care with high CD4 counts, it could be less urgent to start antiretroviral therapy in terms of individual health outcomes "; and added, "These results help provide a new framework of evidence for the benefits to describe variables at the individual level for starting 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 .

If we consider that in Spain the year 2013, 21,9% of new HIV diagnostics occurred in persons over 45 years it is essential to strengthen national efforts to ensure prevention, detection, linking with skilled care, and the early start of treatment and maintenance in the health care system in this segment of the population.

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.

Tradução por Claudio de Souza Santos with support from the Babylon technology and the Review Mara Macedo

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