Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain.
J Antimicrob Chemother. 2010 Mar;65(3):383-5. doi: 10.1093/jac/dkp487. Epub 2010 Jan 12.
The question about when to start antiretroviral therapy in HIV-1-infected patients has been debated since the discovery of the first antiretroviral agent (zidovudine) back in 1986 and has been fuelled by the introduction of highly active combined antiretroviral therapy (cART) 10 years later in 1996. The dramatic improvement in the mortality rate associated with cART supported the principle of 'hitting early and hard', but the initial enthusiasm was quickly tempered by the realization of the inconveniences and the short- to mid-term treatment-related toxicities, including lipoatrophy. In 2009, cART can be very simple and generally well tolerated. All patients with a CD4+ T cell count of <350 cells/mm(3) should receive cART. Moreover, several cohort studies have convincingly demonstrated a significant reduction of AIDS- and non-AIDS-related events when cART is initiated at >350 CD4+ T lymphocytes/mm(3), and even at >500 CD4+ T lymphocytes/mm(3). Also, cART may be considered when there are associated co-morbidities, such as hepatitis C. In addition to individual benefits, an undetectable viral load in response to cART is associated with a substantial reduction in the likelihood of HIV transmission. This can benefit seronegative sexual partners and can potentially diminish the number of new infections, especially if those infected persons unaware of their situation can be identified and advised to initiate cART. Willingness to be treated and to adhere to the prescribed medication still remains the key to success.
自 1986 年发现第一种抗逆转录病毒药物（齐多夫定）以来，关于何时开始对 HIV-1 感染患者进行抗逆转录病毒治疗的问题一直存在争议，1996 年推出高效抗逆转录病毒联合疗法（cART）进一步推动了这一争议。cART 使死亡率显著降低，这支持了“早期及强化治疗”的原则，但初始的热情很快被认识到的不便和短期至中期的治疗相关毒性（包括脂肪萎缩）所削弱。2009 年，cART 已非常简单，且通常具有良好的耐受性。所有 CD4+T 细胞计数<350 个细胞/mm3 的患者均应接受 cART。此外，几项队列研究令人信服地证明，当 cART 在 CD4+T 淋巴细胞>350 个/mm3 时启动，甚至在 CD4+T 淋巴细胞>500 个/mm3 时启动，可显著降低 AIDS 和非 AIDS 相关事件的发生率。另外，当存在丙型肝炎等合并症时，也可以考虑进行 cART。除了个体获益之外，cART 治疗后的病毒载量不可检测与 HIV 传播可能性的显著降低相关。这可以使血清阴性的性伴侣受益，并可能减少新的感染人数，特别是如果能够发现那些不知道自己病情的感染者并建议他们开始 cART。接受治疗和坚持规定的药物治疗仍然是成功的关键。
