SAN FRANCISCO — Treating a recently infected HIV patient may provide some benefit, particularly if that treatment begins before or within a few weeks of antibody seroconversion, Dr. Frederick Hecht said at a meeting on HIV management sponsored by the University of California, San Francisco.
So what should physicians do in practice?
“What I recommend is that we put this in lay language and inform patients of both the risks and the benefits, and the still uncertainties of treating early,” said Dr. Hecht of the department of medicine at UCSF. “There may be some benefit, based on the data, but it is not completely conclusive.”
The current model of acute HIV infection is that T-cell destruction varies in different tissues in the body, and that the worst destruction occurs in the gut, where the majority of the body's T cells reside, particularly memory T cells that express the chemokine (C-C motif) receptor 5 (CCR5) that is a coreceptor for HIV.
Data from simian modeling with simian immunodeficiency virus show that T-cell depletion in the gut occurs very rapidly in infection, and that early treatment can preserve some of these memory T cells, which may allow better immune-system control of HIV over a longer term.
Clinical data in humans on whether early treatment can preserve T cells and reduce viral loads, however, have been conflicting.
Therefore, Dr. Hecht and his colleagues looked at a cohort of 395 patients who were identified early in the course of the infection, and compared the 58 patients who received early treatment with the 337 patients who were not treated as quickly (J. Infect. Dis. 2006;194:725-33).
The early-treatment patients were those who had been treated with at least a three-drug regimen for at least 12 weeks, with the drugs stopped for 4 weeks before the patients' data were examined. The mean duration of treatment was 1.5 years.
The analysis showed that the 13 patients who began their acute treatment within 2 weeks of their seroconversion had significantly lower viral loads, compared with the untreated patients (mean difference between groups, 0.68 log10 copies/mL), and that difference continued for the entire 72 weeks after their treatment ended.
The treated patients also had a slightly higher mean CD4 cell count than did the untreated patients (about 100 cells/mcL higher), and this increase also persisted.
In the 45 patients who began treatment more than 2 weeks after—but within 6 months of—seroconversion, there were lower viral loads and higher CD4 counts at 24 weeks after treatment stopped.
But that advantage waned over time. At 72 weeks, there was no longer any significant difference in viral load, and there was a diminished, albeit still significant, difference in CD4 cell count.
Another reason to consider treating patients early is that doing so will reduce their viral load, which is generally very high acutely, and will thereby reduce the chance that they will spread the virus to others, Dr. Hecht said.
“Acute HIV infection really is an important period for HIV transmission,” he said.