HAART is a combination of at least three antiretroviral drugs from at least two drug classes. Randomised trials of its effectiveness have only followed-up patients for a year or less. The effectiveness of HAART over several years has therefore been unknown until now.
Jonathan Sterne (University of Bristol, UK) and colleagues studied over 3,200 patients from the Swiss HIV Cohort Study who had HIV but were free of AIDS when recruited to the study. Patients were included in the latest analysis if they had been examined after January 1996, when HAART became available in Switzerland. A total of 400 patients subsequently progressed to AIDS or died. The investigators compared HAART with no treatment in 2,161 patients and HAART with dual therapy (formerly the best treatment option) in 1,276 patients. The analysis used new statistical methods that account for the fact that patients tend to be treated when HIV depletes their immune system, and tend to remain untreated if their immune system is relatively intact. The researchers found that HAART's effectiveness compared with no treatment increased with time since initiation, and that HAART was less beneficial for patients who were presumed to have contracted HIV via intravenous drug use than for other patients.
Dr Sterne states: "Our results indicate that HAART reduced the rate of progression to AIDS by 86%, and that its effectiveness compared with no treatment increased with time since initiation. These dramatic benefits provide a context for concerns about possible adverse effects of HAART. The very large benefits of HAART that are achievable in developed countries should remind us of the urgency of providing treatment for the millions of people who could benefit in other parts of the world, particularly sub-Saharan Africa" (Quote by e-mail; does not appear in published paper)
In an accompanying comment Brian Gazzard (Chelsea and Westminster Hospital, London, UK) states: "This result confirms the view of every clinician, that the short-term to medium-term prognosis of HIV-seropositive patients has been transformed. Whilst our ability to treat late presenting hard-to-reach groups remains a concern, as does the reduced benefit seen with the present study in intravenous drug users, this transformation in outlook requires a re-evaluation of present policies about HIV testing. Gone is the equipoise requiring detailed consulting about the pros and cons of an HIV test. Knowledge of one's HIV status can be life-saving."
Contact: Dr Jonathan A C Sterne, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR, UK. T) 0117-928-7396 jonathan.sterne@bristol.ac.uk
Comment: Professor Brian G Gazzard, Dept of HIV, Chelsea & Westminster Hospital, 369 Fulham Rd, LONDON SW10 9NH, UK. T) 44-208-746-8239 eileen.witney@chelwest.nhs.uk
Journal
The Lancet