HIV Treatment Recommendations

The International Antiviral Society-USA has released revised guidelines for management of persons infected with HIV, as part of a Journal of the American Medical Association theme issue timed to coincide with the 2012 International AIDS Conference taking place in Washington, DC July 22-27.  As I reveal to Rick in this week's PodMed, I was fortunate enough to attend the press conference where the issue was highlighted, and hear one of the panel members discuss the new guidelines.  The biggest change is the new recommendation that all adults who are HIV infected should take ART, or antiretroviral therapy, regardless of CD4 count. 

The new guidelines are based on a literature review of all medical literature on management of HIV infection since the last report of the International Antiviral Society-USA panel published in 2010.  Data that was published or presented at scientific conferences in the last two years was also included.  When ART should be initiated, options for new and subsequent therapy, methods for monitoring treatment success and quality, management of treatment failure, and the use of ART in special conditions such as pregnancy or the presence of certain opportunistic infections is covered.

The paper states that there is no threshold count of CD4 cells at which starting therapy is contraindicated.  Hmmmm.  Sounds a bit backward to me.  The more affirmative statement might read 'the substantial benefits of ART for achieving viral suppression and reducing or eliminating opportunistic infections among persons infected with HIV are  known, as well as success in eliminating HIV transmission to uninfected people.  Thus people who are HIV infected should be urged to begin ART immediately.'  Easy for me to say, of course, as I am not a politico.

Why is this recommendation so controversial?  Doesn't it stand to reason that keeping a deadly virus under control using medications both preserves the life of the person infected as well as reduces their chances of infecting someone else to vanishingly small odds? That's the conclusion of much research on the subject, but a lot of sound and fury attend such a recommendation.  As Rick and I discuss in the podcast, one huge issue no one addresses convincingly is that of cost.  In the United States the annual cost of ART may be upwards of $10,000.  Many dotted-line analyses seem to conclude that such a price is cheap in comparison to years of life lost when someone succumbs to the host of complications related to unchecked HIV infection, and that is no doubt true.  Yet for many, particularly those who lack health insurance, it's prohibitive.  And that doesn't begin to assess the cost to folks who don't live in "resource rich" countries. So who is buying?

Another concern I have is the long term effects of ART.  If people begin these medications when they find out they are infected, it could potentially add years to the duration of therapy and we don't really know what happens after 20 or 30 years of ART.  A small concern, perhaps, in light of the known outcomes in the absence of effective viral suppression, but there it is. 

Other topics this week include blood vessel inflammation in people who are HIV infected, and a look at who gets infected with HIV among persons born outside the US and who emigrate here, both in the same issue of JAMA, and in Archives of Internal Medicine the relationship between heart attacks and knee and hip replacements.  Until next week, y'all live well.

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Pawan September 8, 2012 at 10:09 am

HIV is the virus that damages the imnume system by killing CD4 cells. A diagnosis of AIDS is given once the CD4 cell count drops to 200 or below. The problem with a person who has HIV coming in contact with the virus again is that the virus is constantly mutating. That could cause serious problems with treatment and the way the body responds to the virus. For instance, if 2 people in a sexual relationship both have HIV, it is possible that they could each have a different strain of the virus. That means that if they have unprotected sex and infect each other with their different strains, medications they are currently taking may not work as well on the different strain, and their bodies may not respond the same way to the different strain, increasing the chance of them becoming sick more quickly. That's why, even if both people in a sexual relationship have HIV, they should have protected sex. The mutation is also the main reason why there is no cure for HIV at this point.

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