Let’s START at the very beginning

An important development in the worldwide treatment and care of HIV-infected individuals was announced earlier this week. Read on to find out what this means for HIV treatment practices moving forward…

In case you haven’t heard yet, the multi-year START (or Strategic Timing of AntiRetroviral Treatment) study to prospectively test whether at-diagnosis initiation of HIV treatment is more beneficial than a CD4-based initiation guideline was prematurely halted on Wednesday. Interim analyses uncovered an overwhelming health benefit when treatment was initiated at diagnosis, rather than waiting until the CD4 count had dropped below 350. This highlights the next major phase in HIV prevention and treatment, as the immediate management of this chronic disease has now been shown in a rigorous international randomized control trial to not only reduce mortality but also prevent illness and complications from this infection.

In addition to the health benefits to the HIV-infected individual, there is a public health benefit to early treatment as well. Effective treatment that ensures viral loads stay low will reduce the epidemiologic spread of disease. HIV-infected individuals will be less likely to transmit the virus to their partners. This is known as treatment as prevention (TasP) and has been part of US treatment guidelines for several years now.

This news couldn’t come at a more important time. And as recent evidence of climbing HIV infection rates in young adults and HIV cluster outbreaks in Indiana IV drug users remind us, sexual health and HIV transmission education remain priorities in this country. Cuomo’s plan to eradicate HIV transmission by 2020 in New York State (which I wrote about a few months ago here) has been met with mixed response, but the plan and the will are there. Hopefully the funding will be there to match.

Internationally, adequate HIV care and treatment remain a true dream. Lack of funds, lack of drugs, and lack of adequate testing and follow-up for patients hinder even the most well-envisioned approaches. Low- and middle-income countries can barely support the HIV and AIDS cases they currently have (tertiary prevention); how can they manage to treat those who aren’t even “sick” yet (secondary prevention), let alone those who haven’t even contracted the disease yet (e.g. primary prevention measures like PrEP)?

I worked with an Infectious Disease doctor in Peru at the Hospital Regional de Loreto whose HIV clinic was an education in and of itself of low-resource medicine. We discussed the difference in strategies on HIV treatment and prevention that I had seen in NYC with what was standard practice in Peru (per the WHO recommendations of waiting until a CD4-count had fallen at least below 500 but definitely by 350). We agreed that, surely, the upfront financial and manpower investment of primary and secondary prevention measures would be substantial, but that in the long run, the prevention would pay for itself — both in reduction of transmission as well as reduction in complication rates. The problem was who would invest now for the payoff later?

This, I believe, is both as much an issue of absolute resources (Peru being considered a middle-income country) as well as relative priorities internationally. Two changes must occur. First, HIV must be increasingly acknowledged as a chronic infectious disease; it is unlike acute infections that are largely treatable, such as tuberculosis, malaria, and diarrheal diseases. Second, HIV must be deemed worthy of substantial long-term funding, with an understanding that the benefits won’t materialize for many years to come.

Now that there is more hard evidence to support the idea of treating patients at diagnosis, let us bring this idea to the world stage and get ahead of the HIV curve.

A very good place to start, don’t you think?

 

Image Credit:  CapitalWired.com.