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New British guidelines recommend treatment for everyone with HIV
Keith Alcorn, 2015-06-24 12:20:00
Everyone with HIV who is prepared to take antiretroviral treatment should receive it, regardless of CD4 cell count, new draft
British HIV Association (BHIVA) treatment guidelines recommend.
The new draft guidelines, published for consultation this
week, say that anyone living with HIV who understands the commitment of
treatment and is ready to start should receive treatment. The change – from a
recommendation to start treatment before the CD4 cell count falls below 350
cells/mm3 to treatment for all – follows the results of the START
trial, a keenly awaited international study of when to start treatment.
The START study showed that starting treatment at a CD4 cell
count above 500 cells/mm3 reduced the risk of death or serious
illness by 53% compared with waiting to start treatment until the CD4 count
fell to 350 cells/mm3. Although the absolute risk of death or
serious illness was small – 3.7% of people in the deferred treatment arm became
seriously ill or died, compared to 1.8% in the immediate treatment group over
three years of follow-up – the BHIVA guidelines committee concluded that the
evidence now supports offering treatment to everyone prepared to take it.
Two other recent studies, the Temprano study and HPTN 052,
also influenced the decision to offer treatment to all. Temprano,
a study conducted in West Africa, showed that starting treatment at a CD4
cell count above 500 reduced the risk of serious illness and death by 44% when
compared to starting treatment at lower CD4 counts.
The HPTN 052 study, carried out in sub-Saharan Africa,
India, Brazil, Thailand and the United States, showed
that early treatment – starting at a CD4 cell count between 350 and 550 –
reduced the risk of clinical illness by 40% but did not significantly
reduce the risk of death when compared to starting treatment at a CD4 cell
count below 250 cells/mm3.
052 also showed that earlier treatment reduced the risk of sexual transmission
of HIV by 96%. That finding formed the basis for BHIVA’s previous
recommendation that anyone living with HIV should be enabled to start treatment
if they thought that it could reduce the risk of HIV transmission – and that
all people living with HIV should be informed by their doctors of the evidence
linking antiretroviral treatment to a reduced risk of transmission. Surveillance
data presented by Public Health England earlier this year show that this
recommendation coincided with a substantial increase in the proportion of
people starting treatment at CD4 counts above 350 by the end of 2013 – but only
27% of people started treatment at a CD4 cell count above 500 in that year.
The updated guidelines continue to emphasise this evidence,
and recommend that doctors should continue to discuss the potential for
reducing transmission with all people living with HIV. People with HIV should
be assessed for readiness to start treatment after diagnosis, but treatment
initiation should only be considered urgent for people with AIDS-defining
infections, serious bacterial infections or a CD4 cell count below 200 cells/mm3.
People in any of these categories should start treatment within two weeks, the
Recently infected people – anyone diagnosed with primary HIV
infection within 12 weeks of a previous negative test – should be encouraged to
start treatment immediately in order to improve immune recovery, limit the size
of the viral reservoir and limit the potential for onward transmission at a
time of very high viral load. Anyone diagnosed with primary HIV infection who
has a CD4 cell count below 350 cells/mm3, an AIDS-defining illness
or neurological symptoms should also be encouraged to start treatment as soon
as they can. Other people diagnosed soon after infection should be invited to
consider starting treatment in the same way as any other person diagnosed with
HIV – when they feel ready.