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Initial
Plasma HIV-1 RNA Levels and Progression to AIDS in Women and Men
[Sterling TR, et al. NEJM 2001;344:720]: The
investigators from Hopkins reviewed the sequential clinical features
of HIV infection and correlated them with viral load tests done
at six month intervals for a cohort of 156 men and 46 women injection
drug users from 1988 through 1998. The results showed a median initial
viral load of 50,766 c/mL in men compared to 15,103 c/mL in women
(p < 0.001). The baseline CD4 cell counts were 659 and 672/mm3
for men and women, respectively. The risk of progression to AIDS
was the same for men and women. The median initial viral load for
those who progressed to AIDS was 77,822 c/mL for men and 17,149
c/mL for women. The authors note that the DHHS guidelines recommend
antiretroviral agents for those with viral load >20,000 c/mL.
On the basis of this recommendation, 74% of men and only 37% of
women would have been candidates for these drugs despite the fact
that the rate of progression was the same.
Comment:
This report verifies several others that have addressed the issue
of differences in viral load for men and women. There are three
important observations that should be noted: First, CD4 cell counts
seem to be comparable in the two groups and would serve as a reliable
indicator for antiretroviral drugs. Secondly, the differences in
viral load were greatest in the first few years after seroconversion,
but these differences decreased during the subsequent course, so
that they were far less pronounced at the time when decisions regarding
antiretroviral drugs were likely to be made. Third, the DHHS guidelines
were officially changed February 5, 2001, so that the threshold
to initiate therapy was changed from 20,000 c/mL to 55,000 c/mL,
and even then, the recommendation was qualified by the statement
that many utilize the CD4 cell count to make the decision regarding
initiation of antiretroviral treatment. Perhaps more intriguing
is the biologic explanation for differences, which now seem well
confirmed. To date, there is no clear reason for a difference, and
the rate of progression from time of transmission appears to be
the same.
posted
3/29/2001
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