HAART Rules

Liberal use of highly active antiretroviral therapy for HIV infections, the kind of regimen that makes the virus undetectable in an infected patient, has been the mantra of the International AIDS Conference in Vienna this week. It’s been promoted as a strategy to both help HIV-infected patients as well as to help those who are not yet infected and wanting to stay that way.

image by Mitchel Zoler

The revised HIV treatment recommendations from the International AIDS Society-USA, released July 18, reset the threshold for starting HAART in asymptomatic patients from 350/mcL CD 4 cells to 500/mcL, as well as provided a list of eight special situations that also warranted treatment in asymptomatic patients. Even more aggressively, it said starting treatment could be considered for any asymptomatic patient, regardless of CD 4 cell count, saying that no contraindication existed for treating HIV infection at any CD 4 cell level.

But it was hard to see treatment of these patients as merely a consideration when the chairwoman of the recommendations panel, Dr. Melanie A. Thompson, said that “at any CD 4 count the body takes a hit from uncontrolled HIV infection,”  that’s believed to show up later as cardiovascular, renal, and hepatic complications, as well as cancer. She also said that one of the major, prior reasons to wait on starting treating–to avoid possibly wasting one or more of a limited panel of drug treatment options–has become much less of a concern because now more drug options exit, and the new options have good tolerability and potency. Here is my full report on the treatment recommendations.

But there is more to like about widespread, and early HAART: It also helps the community as a whole avoid HIV infections, Dr. Julio S.G. Montaner said in a talk on July 21 and in a paper that appeared last week in The Lancet. He assessed the impact of HAART on HIV transmission rates in British Columbia, Canada, and found a strong link between an increased number of HIV-infected patients on effective HAART and a substantial drop in new HIV infections. The way this works is if HIV-infected patients are on HAART and have an undetectable viral load they are much less likely to pass the infection on to someone else.

In his analysis, Dr. Montaner found that for every 100 additional HIV-infected patients on HAART the number of new HIV infections in British Columbia dropped by 3%, and that for each 10-fold drop in the “community viral load” of HIV the number of new infections fell by 14%.

Of course, many challenges remain, such as identifying people infected with HIV when they’re asymptomatic and still have high CD 4 cell levels, and paying for all this HAART.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Family Medicine, Health Policy, IMNG, Infectious Diseases, Internal Medicine

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