Ten years after the introduction of highly active antiretroviral therapy (HAART), HIV treatment continues to improve, with today’s drug regimens eliciting better viral control than those of the past with far fewer serious side effects.
Yet despite the steady evolution of HIV therapy, a newly released study shows no corresponding decline in death rates or progression to AIDS among patients from North America and Europe who were followed for up to a year.
Just over 22,000 patients starting therapy for the first time were included in the study, which appears tomorrow in the journal The Lancet.
The findings do not mean that HAART is not saving lives or keeping HIV-infected people from developing AIDS.
All agree that today’s drug regimens are remarkably effective. So effective, in fact, that one study found the nine out of 10 patients who stay on the treatment can expect to live for more than a decade.
Rather, the findings seem to reflect the changing face of HIV infection in Europe and North America, experts say.
Researchers found that in 2003, patients tended to be sicker when they started treatment than those beginning treatment in 1995. And that the number of AIDS cases seen in recent years is related to an increase in cases of tuberculosis.
Compared with patients starting HAART for the first time in 1995, those starting therapy in 2003 were far more likely to be female and infected with HIV through heterosexual rather than homosexual contact.
--The percentage of female patients starting therapy increased from 16 percent in 1995-1996 to 32 percent by 2002-2003.
--During the same period, the percentage of men who became infected through sexual contact with men declined from 56 percent to 34 percent.
--The percentage of patients presumed to have become infected via heterosexual contact increased from 20 percent in 1995-1996 to 47 percent in 2002-2003.
--The percentage of patients infected via injected drug use declined from 20 percent in 1997 to 9 percent in 2002-2003.
The study suggests that homosexual men have benefited the most from HAART. The best viral responses to therapy have been seen among this group, while women and men infected via heterosexual contact have not benefited as much.
‘Disease of Poverty’
HAART has transformed HIV infection from a sure killer to a largely manageable disease among patients who begin treatment early and stay on it.
But many patients in the U.S. have not benefited, says Carlos del Rio, MD, because AIDS is increasingly a disease of the poor and medically underserved.
Del Rio is a professor of medicine and infectious disease at Emory University in Atlanta and co-director of the Emory Center for AIDS Research.
“Twenty years ago AIDS was a disease of middle class, white, gay men, but it is increasingly a disease of poverty,” he tells WebMD. “Patients today are less likely to have access to good medical care, so it is not surprising that they are sicker when we first see them.”
He says many of the HIV-infected patients he now treats also have mental health and substance abuse issues.
“For these patients, HIV is just one more problem in an already problem-filled life,” he says. “They may be dealing with schizophrenia, drug abuse, or any number of other issues. Many refuse therapy or don’t stay on it.”
The fact that mortality has not improved -- even though treatments for AIDS have improved -- underscores the need to focus more on preventing HIV infection, del Rio says.
“HAART has made a big difference, but we can’t rely on therapy alone in this population,” he says.
By Salynn Boyles, reviewed by Louise Chang, MD
SOURCES: Antiviral Therapy Cohort Collaboration report, The Lancet, Aug. 5, 2006; vol 368: pp. 451-458. Margaret May, research fellow, department of social medicine, University of Bristol, U.K. Carlos del Rio, MD, professor of medicine and infectious diseases, Emory University School of Medicine; co-director, Emory Center for AIDS Research. WebMD Medical News: “HAART Adds Years for People with HIV.”