Starting Highly Active Antiretroviral Therapy for HIV Infection: Is It WIHS To Wait?

Since the advent of combination antiretroviral chemotherapy in 1995, we have witnessed one of the most remarkable reversals of fortune in any disease in the history of medicine. In 1984, the median survival for HIV-1–infected persons with Pneumocystis carinii pneumonia was about 6 months; it is now closer to 10 years and might be longer. Nonetheless, it is clear that therapy causes toxicity in some patients and leads to economic costs in all patients. These issues have appropriately triggered discussions about how to individualize therapy to maximize benefit, minimize toxicity, and reduce financial costs to society.

In this issue, Anastos and colleagues' analysis of the predictors of successful outcomes of antiretroviral chemotherapy in women participating in the Women's Interagency Health Study (WIHS) cohort demonstrates that even persons with advanced HIV disease benefit from antiretroviral chemotherapy and that a patient's post hoc response to therapy is more predictive of outcome than are baseline biological variables (1). These findings indicate the resilience of the immune response, the effectiveness of antiretroviral therapy, and the importance of adherence to therapy. Furthermore, the comparability of these data from an all-female cohort with those from male-dominated cohorts argues that, in these aspects of the illness at least, the virus has no sex bias.

Other recent data underscore the reversibility of immunologic damage and the importance of adherence in patients with late-stage HIV disease (2-4). Several studies have concluded that all-cause …