{"id":2313,"date":"2012-01-08T08:54:26","date_gmt":"2012-01-08T13:54:26","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=2313"},"modified":"2015-06-04T15:15:11","modified_gmt":"2015-06-04T19:15:11","slug":"journal-club-in-early-hiv-infection-little-reason-to-delay-therapy","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/journal-club-in-early-hiv-infection-little-reason-to-delay-therapy\/2012\/01\/08\/","title":{"rendered":"Journal Club: In Early HIV Infection, Little Reason to Delay Therapy"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/01\/3383920_blog1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-full wp-image-2314\" title=\"3383920_blog\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/01\/3383920_blog1.jpg\" alt=\"\" width=\"280\" height=\"137\" \/><\/a>Every experienced HIV clinician will recognize the following new-patient scenario:<\/p>\n<ul>\n<li>At least one, but often several negative HIV antibody tests in the past, generally due to being in a &#8220;high risk&#8221; group.<\/li>\n<li>Recent non-specific viral-type illness that, in hindsight, was undoubtedly acute HIV infection, undiagnosed.<\/li>\n<li>Now completely recovered, but found to be newly HIV antibody positive.<\/li>\n<li>Physical exam normal, CD4 500 or higher, HIV RNA in the moderate range (10-100K).<\/li>\n<\/ul>\n<p>How should patients like these be managed? Specifically, should antiretroviral therapy be started, or should they be observed?<\/p>\n<p>Over in <em>Journal of Infectious Diseases<\/em>, the so-called <a href=\"http:\/\/jid.oxfordjournals.org\/content\/205\/1\/87.abstract?sid=f83d0e21-9853-45c3-bf25-0652ca3de171\" target=\"_blank\"><em>Setpoint<\/em> study<\/a> &#8212; a randomized strategy trial &#8212; investigated whether a 36-week period of treatment would delay the need to go on continuous HIV therapy, compared with observation. After 130 of a planned 150 patients were enrolled, a Data Safety Monitoring Board elected to stop the study due to this key finding: \u00a0&#8220;&#8230;\u00a0the higher rate of progression to needing treatment in the Deferred Treatment group (50%) versus the Immediate Treatment (10%) group.&#8221;<\/p>\n<p>Importantly, the findings would have been even stronger in favor of Immediate Treatment if more up-to-date CD4 thresholds (500 rather than 350) were used as a criterion to start therapy. (The study was designed in the mid 2000s.)<\/p>\n<p>How do these results influence practice? As I&#8217;ve <a href=\"http:\/\/blogs.nejm.org\/index.php\/journal-club-even-when-you-think-you-should-wait-its-probably-time-to-start\/2011\/03\/30\/\" target=\"_blank\">noted before<\/a>, patients diagnosed with recently-acquired HIV infection should be counseled that even if treatment is deferred, there is a high likelihood they will need to start treatment relatively soon.<\/p>\n<p>It&#8217;s also time to retire the &#8220;you may have 10 years before needing to go on therapy&#8221; counseling, something we might have been prone to do in the past to soften the blow of someone hearing that they&#8217;re HIV positive. This kind of delay is highly unlikely, and may be limited to the small fraction of patients who have very low HIV RNA and very high CD4s.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Every experienced HIV clinician will recognize the following new-patient scenario: At least one, but often several negative HIV antibody tests in the past, generally due to being in a &#8220;high risk&#8221; group. Recent non-specific viral-type illness that, in hindsight, was undoubtedly acute HIV infection, undiagnosed. Now completely recovered, but found to be newly HIV antibody [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4,5,8,10],"tags":[77,423,979,992],"class_list":["post-2313","post","type-post","status-publish","format-standard","hentry","category-hiv","category-infectious-diseases","category-patient-care","category-research","tag-antiretroviral-therapy","tag-hiv","tag-viral-setpoint","tag-when-to-start"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2313","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=2313"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2313\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=2313"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=2313"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=2313"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}