December 6, 2007
On the eve of World AIDS Day 2007, the U.S. Department of Health and Human Services updated its "Guidelines for the Use of Antiretrovirals in HIV-1 Infected Adults and Adolescents." While not the dramatic change some had anticipated, the revision reflects important shifts in advice about when and how to treat HIV/AIDS. The guidelines now recommend earlier treatment for many HIV-positive people.
The guidelines are developed by a panel of physicians, researchers, and community members who review and interpret the currently available science to develop treatment recommendations. This guidance is provided to assist physicians and people living with HIV/AIDS make informed treatment decisions based on the best available evidence. I am a current member of the panel.
Recommendations about when to start HIV treatment were revised in a subtle, but important, way. Previously, treatment was only to be considered when a person's CD4 count was between 200 and 350. Treatment is now recommended for everyone with CD4 counts below 350, all pregnant women, people co-infected with hepatitis B that requires treatment, and anyone with HIV-associated kidney disease or a history of AIDS-defining illness.
Some expected a recommendation for even earlier treatment, as there is a growing sense among experts that earlier treatment may be warranted, particularly at or below CD4 counts of 500. This position has been supported by the availability of more convenient and better tolerated medications, as well as growing evidence that untreated HIV causes significant damage, even at higher CD4 counts.
Scientific proof of the value of starting treatment at CD4 counts above 350 is currently inadequate to make for a strong recommendation. That doesn't mean that HIV-positive people should not begin treatment above 350, but that the evidence is not sufficiently clear to make a strong recommendation.
Of course, it is impossible to know whether and how to start HIV treatment without knowing one's HIV status. Data suggest that fully 25 percent of Americans who are HIV-positive do not know it. Today, 39 percent of people diagnosed with AIDS only learned of their HIV status within the previous year. These troubling figures point to the need for all sexually active people to take an HIV test at least once each year.
The evolution of HIV treatment recommendations has not been completely linear -- with the "hit hard, hit early" strategy of the late 1990s giving way to a series of more conservative approaches as the limitations of available medications became apparent. Expert thought once again tends to favor earlier treatment. Those of us who lived through the early HAART (highly active antiretroviral therapy) era might greet this idea with a healthy dose of skepticism. Make no mistake, however. This is not 1996. Many people with HIV can now realistically think of living normal life spans if they use available HIV medications.
With this welcomed idea comes the need to increase our focus on diseases of aging, like heart disease, diabetes, and cognitive decline. While it has long been suspected that HIV drugs might contribute to these conditions, recent studies have illuminated the role that HIV itself likely plays in them, as well. As a person with AIDS, I share in the concern about the toxicity of HIV drugs -- I have literally felt it. Although harder to feel, the virus is at least as toxic as the drugs, and likely more so.
The decision about when to begin treatment involves many factors and needs to be based primarily on the welfare of the individual with HIV. Evidence suggests that HIV-positive people on antiretroviral treatment, particularly just after becoming infected, are less likely to transmit HIV to others. The revised guidelines tread gingerly on this subject, but do address it. They suggest that people in mixed-status relationships (where one person is positive and the other negative) or engaging in risky behaviors might consider treatment as a way of reducing their chances of transmitting HIV.
Guidelines were also changed for "treatment experienced" people. Drug resistance testing is now recommended for everyone entering care for the first time and information on two new lab tests (tropism and HLA testing) is included. The panel is working diligently on each section of the guidelines to ensure they reflect the most current thinking and research, and more changes are on the way.
Although these changes do not represent a wholesale reworking of the way HIV and AIDS are treated, a shift is indeed under way. The demands of lifelong drug treatment and concerns about toxicity and drug resistance have led many to delay starting treatment as long as they thought safely possible. However, a tried and true maxim in medicine is that the earlier you treat, the better the outcome.
As the U.S. Centers for Disease Control and Prevention prepare to significantly increase the estimated number of new HIV infections occurring each year, the importance of treatment becomes even more profound. Starting treatment earlier in HIV infection, coupled with better options for those already in treatment, provide both the opportunity to improve quality of life for all HIV-positive people and strengthen our HIV prevention efforts.
For more information about the guidelines, or for comprehensive information about HIV treatment, call Project Inform's National HIV/AIDS Treatment Hotline at 1-800-822-7422.