by Michael Raitt -
SGN Contributing Writer
There is new research out authored by a local researcher and physician, Dr. Mari Kitahata, that has huge implications on how patients and physicians work together to make the most informed decisions about HAART (Highly Active Antiretroviral Therapy) treatment for people newly infected with HIV.
Last month I had the pleasure of listening to Dr. Kitahata present her research at the Seattle/King County HIV/AIDS Planning Council meeting. Members and guests were impressed by the scope of her research. We are very aware of the implications this research has on when treatments are started and the work we have to do as patients, providers and a community to get the word out so patients can be more informed and make health decisions that are best for them.
This research has been published in the New England Journal of Medicine, Volume 360:1815-1826, April 30, 2009, Number 18, and is titled, "Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival," authored by Dr. Mari Kitahat, et al.
I won't go into details explaining the research protocols and the complicated statistical models used (if you are interested in that, you can find the article at www.nejm.com and it will take you to the site and search "HIV"). I will say that this is an expansive, multi-national study - the first of its scope - that has addressed important variables from other studies and that has given an important, new understanding of long-term survival and health for patients who are newly infected with HIV and who start antiretrovirals early.
Every year in our community and state, a few hundred men and women are infected with HIV. Clearly, people are still being infected nationally and internationally. Historically, patients were advised to monitor their CD4 cell count and viral load. Doctors suggested, and many times patients agreed, to wait to start antiretroviral treatments until viral loads were higher and CD4 counts were between 350 to 500. Patients and doctors were concerned about drug toxicity and side effects. This was the standard of care. With all due respect, doctors were going with what they knew at the time and based on research they had and their understanding of the disease.
The research that Dr. Kitahata presents suggests strongly that the prognosis for survival and overall maintenance of health is greater when patients who are newly infected with HIV begin antiretroviral therapies immediately while their CD4 counts are still high and healthy and their viral load is very low.
This research states a couple of important points that people should be aware of. First, drug toxicity is an important consideration for patients when deciding when to begin treatment. As it pertains to drug toxicity and treatment adherence, this research states that "newer antiretroviral therapies that are more potent, have fewer side effects, and have to be taken less frequently improve adherence and maintain viral suppression at lower levels of adherence & starting therapy at progressively higher CD4+ counts has been shown to lower the risk of some toxic effects." This finding may influence the decision a patient makes when considering this aspect of treatment.
A second interesting point that supported beginning antiretroviral treatment early was based around "cumulative viral load." My understanding of this term was that cumulative viral load was a number that was used to represent how much virus there has been in an individual as it fluctuated over time (I don't know whether it is an actual number or a concept). What is important is that cumulative viral load has an impact on overall health, organ systems, and long-term survival. What I extrapolated from this was that it is much more beneficial to keep the cumulative viral load very low for optimal health and long-term survival. In other words, if you are newly infected and your viral load is very low, CD4 count is healthy, you start antiretroviral treatments and your viral load stays low or is non-detectable for a long period of time, the research indicates your chances of long-term survival and maintaining a higher level of health are greater.
In her presentation at the Planning Council, Dr. Kitahata stated that HIV is a "very complex" disease and that researchers and doctors are continuing to understand the impact it has on the immune system and organ systems. Dr. Kitahata did state that the research seems to indicate that patients who started antiretroviral therapy early, when they were very healthy and viral loads were down and CD4 counts were high, were generally able to maintain that level of health. Likewise, those who started their treatments later after the viral load was higher and the CD4 levels decreased could maintain a certain level of health but they were not able to regain that higher level of health they had early in the infection or prior to infection.
In this area, when you are newly infected, you have an opportunity to meet with Dr. Bob Wood of King County Health. He has been working with HIV+ patients and newly infected patients for years. He is excellent and you can ask him about this study and the implications of starting antiretroviral therapies early or waiting until your CD4 counts are lower and your viral counts are higher. As well, the physicians I know of - Dr. Vy Chu, Dr. Peter Shalit, Dr. Jeff Olliffe, Dr. Rob Killian, and the physicians at Madison Clinic - are experts in their fields and have excellent reputations in working with their HIV+ patients. If you are, or become, a patient of theirs, talk to them about this research.
I recognize that the study that Dr. Kitahata has done is very comprehensive and that my summary of it is very cursory and brief. My sole purpose in this thumbnail presentation of the study is to provide people with some new, interesting data and give them at least some information that they can use to advocate for themselves or to pass on to friends who are newly infected. Ultimately, to advocate for yourself as a patient, you have to have as much information as you can. Educate and inform yourself. Challenge your doctors and providers and push them to get this information and education so they can provide advice that is in your best interest. We need to keep talking about this and making sure everyone has as much information as possible that will benefit our selves and our loved ones and keep individuals and our community healthy.
Advocate for yourself. This is big news and has huge implications for the health of the people we love and the future of our community. Get the word out! Hopefully this research will contribute to a shift in the, "standard of care" for newly infected individuals so they live healthier, longer lives. Thank you, Dr. Kitahata, et al.
Michael Raitt, MA LMHC, is a therapist and a contributing writer to the SGN. He writes a bi-monthly column in the SGN. If you would like to comment on this column, ask a question you'd like him to write about, or suggest another topic of interest, please contact him at firstname.lastname@example.org.
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