Risk of progression to AIDS and death in women infected with HIV-1 initiating highly active antiretroviral treatment at different stages of disease.

Abstract

THE INTRODUCTION in 1996 of highly active antiretroviral treatment (HAART) regimens¹ for individuals infected with the human immunodeficiency virus (HIV) type 1 (HIV-1) has resulted in marked decreases in HIV-related morbidity and mortality in the United States and Europe.^2-4 It has been documented that individuals at more severe stages of disease are more likely to receive HAART.⁵ Despite this selection by indication, cohort studies have clearly shown that the disease burden (incidence of acquired immunodeficiency syndrome [AIDS] and mortality) has been drastically reduced at the population level.^2,6 However, the heterogeneity of response among those individuals who are treated remains uncharacterized. Because of the paucity of data on long-term clinical outcomes among individuals initiating therapy at different clinical, virologic, and immunologic stages of disease, the optimal time at which to initiate HAART remains undefined. The guidelines for treatment developed and implemented in different countries thus vary in the levels of immunosuppression at which to initiate therapy^7-10 and are changed frequently.¹⁰ Although it has been suggested that HIV should be "hit early and hit hard" with antiretroviral therapy,¹¹ recent reconsideration has led some to suggest that we "hit HIV-1 hard, but only when necessary."¹²