Clinical Benefit of Continuing a Failing HIV treatment Regimen in AIDS Patients

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Summary and Comment

Clinical Benefit of Continuing a Failing ART Regimen in AIDS Patients

In a large study of patients with CD4 counts <200 cells/mm3, the risk for a new AIDS-defining event was 22% lower during periods of virologic failure on ART than during treatment interruptions.

Studies of treatment interruption in salvage therapy have yielded disappointing results (ACC Oct 1 2003). However, the benefits of continuing a failing antiretroviral regimen in a salvage setting are also questionable. Now, investigators in France have compared the clinical outcomes of stopping antiretroviral therapy (ART), continuing a failing regimen, and maintaining suppressive ART in patients with AIDS.

The 12,765 study participants received ART between 2000 and 2005 and had CD4 counts <200 cells/mm3 while receiving such treatment. Of these patients, 18% had at least one treatment interruption lasting 3 months, 69% had at least one period of virologic failure (2 consecutive viral-load measurements 500 copies/mL), and 51% had at least one period of virologic suppression (2 consecutive viral-load measurements <500 copies/mL). Investigators compared the incidence of AIDS-defining events during treatment interruption with the incidence during virologic failure and the incidence during virologic suppression. Thirty-four percent of patients were included in more than one of these exposure groups (for example, a single patient could have contributed data during both a treatment interruption and a period of virologic suppression). Results were stratified by the patient’s CD4 count (<50 vs. 50–200 cells/mm3) at the time of entry into a given exposure group.

The rate of new AIDS-defining events (per 100 patient-years) was 18.5 during treatment interruptions, 14.5 during periods of virologic failure, and 4.9 during periods of virologic suppression. Similar differences were noted in both CD4-cell–count strata and for all types of events (viral, fungal, protozoal, bacterial, and other). In a multivariate analysis, risk for a new AIDS-defining event was 22% lower during virologic failure — and 62% lower during virologic suppression — than risk during treatment interruption.

Comment: These data further support the concept that complete interruption of ART has negative health consequences, even in patients who have low CD4-cell counts and limited treatment options. In resource-wealthy countries that have access to new drug classes and new agents that are active against resistant HIV, the goal of ART is to achieve full virologic suppression, even in treatment-experienced patients with broadly resistant HIV. In resource-poor areas where patients lack access to a panoply of new drugs, and in patients who have exhausted all drug classes, these results will help to inform the decision about continuing ART despite persistent viremia.

— Henry, MD

Published in AIDS Clinical Care January 14, 2008

Citation(s):

Kousignian I et al. Maintaining antiretroviral therapy reduces the risk of AIDS-defining events in patients with uncontrolled viral replication and profound immunodeficiency. Clin Infect Dis 2008 Jan 15; 46:296.

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