By Elena Obieta
As the international AIDS conference I’ve been attending in Malaysia draws to a close today, I’ve been reflecting on the new HIV treatment guidelines launched by the World Health Organization on 30 June at the start of the conference.
As a doctor who has sees the sharp end of infectious diseases, I believe impact on incidence should be the first thing to consider. With these new recommendations on HIV treatment, 3 million HIV-related deaths and 3.5 million new infections can be avoided.
Money talks, everybody knows that. And the cost will be just 10% on top of the total resource needs if you compare the new 2013 guidelines with the previous ones from 2010.
Quicker antiretroviral treatment
The new guidelines recommend that people living with HIV should now be referred for antiretroviral drug treatment as soon as their CD4 count goes below 500 cells per cubic millimetre of blood. This count indicates how much of a person’s immune system has been destroyed and 500 is bottom of the normal range. In the previous guidelines treatment was not recommended until the CD4 count fell below 350, but now treatment for people living with HIV should be provided sooner, before their health begins to deteriorate.
In addition, there is special consideration for: people co-infected with TB and/or hepatitis B; children; pregnant and/or breastfeeding women; and serodiscordant couples (when one person in a couple is living with HIV but the other person isn’t). For these people the new guidelines recommend starting treatment immediately upon a positive HIV test, regardless of their CD4 count.
This is good news for helping prevent the spread of HIV. For example, the HIV Prevention Trials Network 052 clinical trial established the importance of early treatment to reduce the risk of sexual transmission of HIV in serodiscordant couples. This was a groundbreaking study from 2005-2011 which proved treating people with effective drugs against HIV reduced the chance of transmitting the virus to their partner by 96%. Also, maybe for the first time, it showed enough evidence regarding a ‘treatment as prevention strategy’, meaning something like; if there were no cars there would be no car accidents!
Key populations affected by HIV
Although the World Health Organization’s new guidelines are a step in the right direction, unfortunately they make no specific recommendation for people most at risk, like men who have sex with men, drug users, sex workers, migrants or immobile people. The big question is why did they not address these key populations?
Still, if people get to start treatment with CD4 counts less than 500, maybe most of those in need of antiretrovirals will be covered, and that huge evidence of impact could be amplified.
When writing this last line, it comes to my mind what’s going on in Spain. Hundreds of migrants have lost any chance to get health care, including life-saving medicines. People have been forced to interrupt their treatment, including those with AIDS-related illnesses who now have no access to care, due to the financial crisis. Maybe politicians should read some science.
Getting the right drug regimen
There is strong evidence to support the use of fixed dose combination (FDC) treatment – a daily pill that combines three drugs (tenofovir, FTC and efavirenz). This treatment makes it easier for people living with HIV as there is no need for refrigeration and no food restriction. It could work for almost everyone as a first antiretroviral regimen, except for young children.
Children under five years of age should always start treatment, regardless of their immune status (CD4 count), since it is already known that the disease evolves faster than in adults. Those children under three years of age should start with two drugs that belong to the group called NRTIs (nucleoside reverse transcriptase inhibitors), which are not part of the FDC, plus a drug belonging to the protease inhibitors group, which is lopinavir/ritonavir, since the latter has shown better than nevirapine, a drug from another group, which is widely used but not recommended any more for prevention of mother to child transmission.
Lopinavir/ritonavir also has an additional benefit of huge importance: it reduces the chances of getting malaria. But – there’s always a but – it needs refrigeration depending on its formulation and it is terribly untasty as a syrup (as a mother I know how difficult it is to make a child swallow a medicine!).
When talking about children between three and ten years of age, treatment should start with abacavir/3TC/efavirenz. These three drugs unfortunately, do not have a daily fixed dose combination pill (depending on local market/money rules it could mean two or three pills a day). Children older than ten should be considered as adults with regards to antiretroviral treatment and be given fixed dose combination pills.
All pregnant and breastfeeding women should be given triple antiretrovirals, at least for the duration of the risk of transmitting the disease to their baby. Ideally treatment should be kept life long, reducing the risk of transmitting HIV in future pregnancies and also for serodiscordant couples.
Though I am optimistic following the new guidelines, there are still some worrying issues. These are mainly in relation to low coverage for testing, and as a consequence delayed diagnosis and treatment. And last but not least, there is still an urgent need to respond to the multiple needs of people living with HIV, many of whom are struggling with poverty, such as: food, safe water, and literacy.
Politics should ask from science what to do, not the other way round.
Elena Obieta is an infectious diseases physician in HIV and TB and lives in Argentina. She is also a member of the Key Correspondents programme which focuses on marginalised groups most at risk of HIV and people living with HIV, to report the health and human rights stories that matter to them. The programme is supported by the International HIV/AIDS Alliance.