Editors' ChoiceHIV/AIDS

The Early Bird Gets the Virus

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Science Translational Medicine  13 Feb 2013:
Vol. 5, Issue 172, pp. 172ec28
DOI: 10.1126/scitranslmed.3005830

Although AIDS is an infectious disease, it is not treated immediately after diagnosis—largely because there is no randomized clinical trial data showing clinical benefit for early initiation of antiretroviral therapy. Nevertheless, the observational data are strong, and in well-resourced settings, antiretroviral drugs are given to most HIV-positive persons as soon as feasible. In a recent study, Le et al. provide evidence that initiating antiretroviral therapy within four months of HIV infection improves recovery of immune function better than does later treatment.

The authors followed 213 participants who started antiretroviral therapy within about 4 months of HIV infection and 384 participants who waited to start therapy for at least 4 months. They used CD4 T cell recovery as a marker of response. HIV targets CD4 T cells (which are important for immune function). Without treatment, the number of CD4 cells initially falls precipitously after infection, transiently increases over the first 4 months, and then steadily declines. With standard antiretroviral therapy, CD4 count and immune function improve, but usually not to their preinfection levels. In contrast, the investigators found that in 64% of participants who started treatment within 4 months of HIV infection, CD4 cell counts recovered to pre-HIV levels (more than 900 cells/mm3). Only 34% of those who waited at least 4 months to start therapy showed such a dramatic response.

Initiating antiretroviral therapy within 4 months of infection is not without challenges: Identification of newly infected persons is difficult, and a clear clinical benefit of very early ART initiation has not yet been shown. However, the approach is promising because very early HIV treatment may limit the damage to the immune system and decrease the initial viral reservoir, opening the door for complete clearing of HIV and a potential cure.

T. Le et al., Enhanced CD4+ T-cell recovery with earlier HIV-1 antiretroviral therapy. N. Engl. J. Med. 368, 218–230 (2013). [Full Text]

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