25 November 2010
A new study says delaying treatment for people infected with HIV can have long-term health and financial consequences. The findings add to the debate over when anti-retroviral treatment should begin.
A growing body of research says starting HIV-infected people on drug treatment sooner is better for the patient. Initially, the drugs were given when a person's CD4 immune cell count fell to 200 or below. By that time, the patent could have full-blown AIDS.
Now the general recommendation is to start treatment when CD4 counts reach 350 – before the immune system collapses. Despite that recommendation, many people are receiving delayed treatment.
Looking at the evidence
Dr. Kelly Gebo – a Johns Hopkins University professor of Epidemiology – is the senior author of the study. Gebo and her team reviewed the medical records of more than 8,000 patients in the United States between 2000 and 2007.
"So, we actually didn't look at when to start treatment. We looked at when people presented for care. And we found that unfortunately nearly half of people – 43 percent of people – were presenting late for care. And those people cost more over the long run," she says.
Gebo says the study did not look at why treatment was delayed, but the findings did give a few hints.
"One of the things anecdotally that we do tend to find," she says, "is that people are hospitalized for a severe opportunistic illness and then sort of follow-up for outpatient care. They may have known they were HIV infected for a long period of time and not come for care just because they didn't feel bad or everything was going well. And then when something catastrophic happens is when they start embarking on care."
CD4 countdown
Once a person is infected with HIV, unless treatment is given, there's usually a long but steady decline in CD4 cells. So, symptoms of the disease may not appear right away.
Gebo says, "Most people have a CD4 count between 800 and 1200. So we say an average of a thousand. And in HIV when we didn't have antiretrovirals the average CD4 count fell by about a hundred cells per year. So we said it was about eight years from infection to development of AIDS. And in general, it was about a 10-year life expectancy. Now, with antiretrovirals, the whole ballgame has changed."
Earlier treatment with antiretrovirals gives a person a much better chance of avoiding other illnesses besides full-blown AIDS.
"So clinically we know that people do better," she says, "They have fewer opportunistic illnesses. They seem to have fewer non-traditionally AIDS-related events. So, cardiovascular disease, malignancies, end stage liver disease, end stage renal disease – all appear to be higher in HIV-infected patients. So treatment with antiretrovirals has been shown to slow the progression of some of those."
And then there are the medical costs
The average difference - between those receiving treatment early and those who didn't - ranged from about $27,000 to more than $60,000 over the first seven to eight years. Costs are higher for the so-called late presenters because they are often sicker than early presenters.
"We did look at direct medical costs. And in the direct medical costs, it was certainly cheaper with treating people with antiretrovirals, even given the cost of 10 to 12 thousand dollars a year for antiretrovirals when you look at the reduction in hospitalizations, other medications used and some of the other outpatient utilization and laboratories that we evaluate in our study," she says.
And earlier treatment allows people to be more productive longer.
While the study was not done in a developing country, the findings may provide guidance. Some countries in sub-Saharan Africa, for example, are debating whether to start antiretroviral treatment earlier. However, that means spending more on HIV/AIDS at a time when many economies are still reeling from the global recession.
More details on the study can be found in the December issue of the journal Medical Care.