March 4, 2009
Dr. Margaret Chan
World Health Organization
Avenue Appia 20
1211 Geneva 27
Re: Revising WHO Guidelines for CD4+ T-Cell Treatment Initiation Threshold to Reflect Current Data
Dear Director General Chan and Mr. Sidibé,
In light of scientific evidence correlating earlier treatment with vastly improved health outcomes and lower death rates, we the undersigned HIV/AIDS medical care providers and advocates call on the World Health Organization (WHO) and UNAIDS to immediately revise its current guidelines to raise the recommended treatment initiation threshold from a CD4+ T cell count of <200 cells/mm3 to <350.
The Health Ministry of Uganda has recently expanded eligibility for enrollment in the national antiretroviral program by raising the eligible CD4+ T cell count to <350 from <200 because the previous guidelines were "inadequate" to meet the needs of the people. That kind of proactive leadership is needed at a global level from WHO and UNAIDS.
Based on a growing body of evidence supporting earlier treatment, a number of health agencies -- including the U.S. Department of Health and Human Services and the International AIDS Society, USA -- have updated their guidelines to recommend treatment initiation at <350. As WHO strives to lead the fight against the global HIV/AIDS epidemic, the agency's guidelines must also be updated to reflect these current data.
The trend toward earlier treatment initiation is based on several factors. First and foremost is the mounting evidence demonstrating its major positive health impacts, including improved survival and reduced disease progression. In addition, several studies have shown that earlier treatment initiation is a cost effective intervention, reducing healthcare costs by preventing the need for extended hospital stays, as well as improving life expectancy.
Other factors in the movement toward earlier initiation include the vast improvement in the effectiveness and tolerance of newer antiretroviral medications and the fact that successfully treated patients are at a lower risk of transmitting the virus.
HIV/AIDS patients in high-income, industrialized nations are now benefiting from updated guidelines based on these new data. However, it is in resource-constrained settings -- for which WHO guidelines are largely intended -- that an earlier treatment threshold would make the most significant difference. Under health policy guided by the current WHO recommendations, an HIV-positive patient with a CD4 cell count greater than 200 seeking treatment in a resource-constrained country, such as many in sub-Saharan Africa, is likely to be told to return months later when his/her HIV infection may have progressed. Within those months, opportunistic infections could take that patient's life -- a death that could be prevented by earlier initiation of treatment.
The leadership of both WHO and UNAIDS on this issue will have an enormous impact on the clinical practices in resource-constrained countries reliant on the agency's guidance to shape national health policy. In November of last year, when a large-scale study conclusively confirmed the benefits of early treatment for HIV-positive infants, WHO responded by revising its treatment initiation guidelines, recommending HAART for all infants under 12 months of age with confirmed HIV infection, irrespective of clinical or immunological stage. A similar revision must now be made to benefit the tens of millions of adults living with HIV/AIDS worldwide.
Raising WHO's recommended treatment initiation threshold from a CD4+ T cell count of <200 to <350 would remove one more barrier to accessing lifesaving HIV/AIDS treatment and have a positive economic impact on resource-constrained countries, ultimately reducing the healthcare costs associated with the treatment of preventable HIV/AIDS-related conditions. Most importantly, this change could significantly improve health outcomes, increasing the odds of survival for millions of people living with HIV/AIDS in the developing world.
We urge WHO and UNAIDS leadership and action on this matter and look forward to your response.
Michael Weinstein, President
AIDS Healthcare Foundation
Homayoon Khanlou, MD, Chief of Medicine USA
AIDS Healthcare Foundation
Chinkholal Thangsing, MD
AHF Bureau Chief, Asia Pacific Bureau
Bernard Okongo, MD
AHF Bureau Chief, East / West Africa Bureau
Patricia Campos, MD
AHF Bureau Chief, Latin America Bureau
Ndilikazi Buhlungu, MD
AHF Bureau Chief, Southern Africa Bureau
AHF Senior Bureau Advisor, East/West Africa
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