Roger J Pomerantz; David L Horn


Nat Med. 2003;9(7) 

In This Article

2002: Prevention of HIV-1 Neonatal Transmission in the Developed World; New Guidelines for Initiating HAART

When HAART was first introduced, the dogma for HIV-1 therapy was, "hit HIV early and hard."[62] It was believed that following this strategy, HIV-1 could be eradicated with a prolonged course of combination antiretroviral therapy. The initial enthusiasm for initiating therapy early was tempered by the recognition that standard antiretroviral therapy would probably not lead to eradication and, therefore, that therapy would need to be sustained indefinitely, which could prove difficult for many patients. Several considerations—the frequent occurrence of adverse events and metabolic complications directly related to therapy, the difficulties of adherence to as well as the high economic costs of HAART, and the potential for the development of resistance—led to detailed risk-benefit analyses of early therapy versus a delay in the initiation of therapy until later in the course of disease. Accumulating data, moreover, showed that immune reconstitution was achievable even in those individuals with very low CD4+ T-cell counts, and the time to diagnosis of AIDS or mortality was no different in those individuals who were treated early versus those offered delayed therapy. Based on all these considerations, guidelines were changed to recommend that therapy should be initiated in asymptomatic individuals when their CD4+ T-cell counts drop to between 200 and 350 cells/mm3.[61] We must, however, be careful not to let the pendulum swing too far in the other direction, as waiting too long to initiate HAART may have adverse outcomes in certain patients. Ongoing research will help us to stratify patients based on the most opportune point at which to begin HAART.[63]

Additional drugs have been developed that can be used as part of HAART ( Table 2 ). The addition of these drugs to the armamentarium against HIV-1 has been helpful because of their different profiles of adverse events and resistance mutations, allowing more convenience or modifications in HAART as required. In the developed world, the advent of HAART has propelled further progress concerning the prevention of perinatal transmission of HIV-1 which can now be prevented in nearly 99% of cases.[64]