By Anthony J. Brown

Reuters 2 February 2001

New York -- Revised AIDS treatment guidelines call for delaying antiretroviral therapy in patients who have no symptoms, US government researchers will announce Monday. The new recommendations aim to reduce the toxic effects of the powerful drugs HIV-infected people take to fight the virus.

"The philosophy of the original guidelines was to hit hard and hit early,'' Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (news - web sites), told Reuters Health Thursday. "That philosophy was reasonable if you assumed that antiretroviral therapy could eradicate the virus and ultimately get people off therapy.''

However, Fauci explained, since clearing the virus completely is not currently possible, people will likely need to keep taking their medicines indefinitely. "This shifts the risk-benefit ratio to looking at the long-term toxicities of treatment,'' he said.

"If you look at people who have been treated for many years, there is an increasing incidence of toxicities...and emergence of resistant organisms,'' Fauci added.

The hallmark of HIV infection is damage to the immune system. Dropping levels of a type of white blood cell called CD4+ cells is a sign doctors use to monitor this destruction.

Previously, antiretroviral therapy was recommended for symptom-free patients who had 500 CD4+ white blood cells per microliter of blood, or 10,000 copies of the virus per milliliter of plasma according to a measurement called branched-DNA testing.

The current revision calls for delaying treatment until the CD4+ cell count is less than 350 cells/microliter, or the viral load is greater than 30,000 viral copies by branched-DNA testing. In essence, "we are setting the bar at a more advanced stage of disease,'' Fauci noted.

Current research suggests that delaying treatment in this way will not impact survival or time to development of an AIDS-defining illness, Fauci pointed out. But this delay may help reduce the incidence of the toxic cumulative side effects linked to the "cocktail'' of drugs HIV patients take.

Fauci emphasized that the treatment revisions were for asymptomatic patients only. Guidelines for patients who have symptoms, or whose CD4+ cell counts are less than 200 cells/microliter have not changed.

The revised guidelines, a joint effort of the Department of Health and Human Services and the Henry J. Kaiser Family Foundation, will be released on February 5.