Clear evidence against episodic HIV treatment

Home > PJ (current issue) > News / News Centre | Search

The Pharmaceutical Journal
Vol 277 No 7429 p659
2 December 2006

This article
Reprint Photocopy

Acrobat Reader

Clear evidence against episodic HIV treatment

HIV-infected patients are at increased risk of opportunistic disease or death if they are treated using a strategy of episodic antiretroviral therapy guided by their CD4+ count, rather than given continuous antiretroviral therapy, say researchers in The New England Journal of Medicine (2006;355:2283).

SMART treatment groups

Patients with CD4+ counts of more than 350 cells per cubic millimetre were randomised to episodic or continuous antiretroviral therapy.

Patients in the episodic treatment group had antiretroviral therapy deferred until their CD4+ count decreased to less than 250 cells per cubic millimetre.

Treatment was then continued until their count rose to more than 350 cells per cubic millimetre.

The latest evidence against such a treatment strategy, which the researchers describe as “clear and compelling”, is from the so-called SMART (strategies for management of antiretroviral therapy) study. The study was halted early in January when an analysis of interim data revealed that subjects on episodic treatment (see Panel right) had more than twice the risk of disease progression than those taking continuous antiretroviral therapy (PJ, 28 January, p98).

The full report of the trial, which involved 5,472 patients followed for an average of 16 months, shows that the hazard ratio for opportunistic disease or death from any cause among patients treated episodically was 2.6 per cent (95 per cent confidence interval 1.9–3.7; P<0.001).

The researchers explain that interruption of antiretroviral therapy has been advocated as a treatment strategy to enhance quality of life, limit adverse events and allow for the emergence of wild-type virus in patients infected with multidrug-resistant HIV.

A recent study showed that the strategy could result in significant cost savings with no evidence of treatment resistance (PJ, 12 August, p182).

However, the researchers conclude that the episodic treatment strategy used in the SMART study is deleterious, and did not reduce the risk of death from causes other than opportunistic disease as they had expected.