Under the new policy, those who test positive will begin ARV treatment immediately -- which is a radical shift from the decade-long strategy of waiting until the patient's CD4 count drops before a certain level. The policy is defended in two ways: First, that studies increasingly evidence that there can be significant damage done by the virus to HIV-positive people who do not begin treatment immediately. Second, that reducing viral loads in HIV-positive people will reduce rates of transmission:

A growing body of evidence indicates that HIV causes detrimental effects throughout the body long before the CD4 count falls into the "danger zone" for opportunistic infections (OIs).

The large SMART treatment interruption trial found that patients who stopped therapy when their CD4 count rose above 350 cells/mm3 -- and therefore had periods of unchecked viral replication -- not only had a higher rate of OIs and AIDS-related death, but also of non-AIDS conditions including cardiovascular, liver, and kidney disease.

Early treatment has been linked to decreased risk of morbidity and mortality even at CD4 counts above 500 cells/mm3. Many experts are convinced that chronic inflammation due to ongoing HIV replication contributes to non-AIDS conditions and what appears to be accelerated aging in people with HIV.

Another benefit of early ART is that it lowers the risk of HIV transmission, since treated HIV positive people have lower viral loads than untreated individuals, regardless of CD4 cell count. In 2008, Julio Montaner and colleagues from British Columbia presented a mathematical model showing that treating all people with HIV according to ART guidelines (which then had a CD4 count threshold of 350 cells/mm3) could dramatically reduce the rate of new infections.

At least two things worth mentioning:

1. This policy would put people on meds who may not need them until there are better, less toxic drugs available. For instance, someone diagnosed today may not have gone on them under previous guidelines for another two years. In two years, its possible that there will be ARVs available with fewer side effects.

2. Obviously, if implemented, this would eliminate the possibility of long-term non-progressors (a rare group of positive people who can live healthfully for many years before ARV therapeutic intervention is necessary). A friend of mine in SF who was infected in the mid-80s just went on ARVs for the first time. A very rare situation, indeed. But still worth mentioning.

Thoughts?

Michigan journalist and HIV-positive activist Todd Heywood has an outrageous and upsetting story posted on his site detailing the kinds of struggles he faced recently when trying to get access to post-exposure prophylaxis treatment for a sexual abuse victim:

I accompanied a 2[0-something] who had been the victim of a sexual assault to the hospital on Nov. 21. His experience, and mine with the Sexual Assault Nurse Examiner Justine, was more than acceptable. However, the victim requested a prescription for post exposure prophylaxis- which is a combination of antiretroviral medications taken over a 28 day time period to prevent infection with HIV. Because this was a stranger sexual assault, the HIV status of the assailant was unknown.

This victim and I spent four hours in the E.R. to receive a prescription which should have taken no more than an hour. Sadly, the E. R. Dept. Supervising doctor was unwilling to prescribe the medications, as is recommended by the Centers for Disease Control and Prevention in Atlanta for NonOccupational Post Exposure Prophylaxis (nPEP). In fact, this doctor, a Dr. Moreno was rude, uninformed, and provided several falsehoods to the victim in denying him access to necessary medications.

The CDC has a 24 hour hotline for doctors / clinicians to call if they are unsure of what drugs are appropriate to prescribe in a given situation. The issue of time is signficant here: The drugs are more effective the sooner you start them, and after 72 hours that effectiveness drops dramatically. So getting access quickly is key -- and ease of acesss is also key. This patient had an advocate there for him willing to fight for him, which seems largely to be the reason he ended up getting access -- FINALLY:

Dr. Moreno left the patient to talk with the Risk Management person, a Mr. Cole. And also provided a tablet with CDC guidelines of PEP in occupational exposure situations- which was not the case in a sexual assault, as you can imagine. Right there in paragraph two of the occupational exposure guidelines by the CDC was an 800 number staffed by CDC experts on PEP. Did your doctor find this number and call it?

No, that was left to me. The doctor from the CDC, upon presentation of the clinical facts- 22-year-old, unprotected, nonconsensual same sex activity in a high prevalency area (defined as have a 1% or higher incidence, which Ingham county has)- nPEP was indicated as an immediate treatment.

Dr. Moreno was given the name and telephone number of this CDC expert, and within minutes, the story changed.

The sad truth here is that doctors are grossly ignorant about these issues, and instead of owning up to their own ignorance, they tend to veil their ignorance under the guise of medical authority -- reacting not helpfully, but angrily. "How dare you challenge my authority! I know what's best." But they don't. And instead of getting the information they need, they deny care to patients. It's disgusting.

I recently had an experience VERY similar to this one. Incidentally, Todd recently interviewed me for an upcoming story on the matter. Look for more on that soon!

Dr. Peter Kilmarch (Chief, Epidemiology Branch, Division of HIV/AIDS Prevention, CDC) gave a presentation today on one of CHAMP's amazing StrategyLab conference calls. I didn't make the call, but I did check out the Powerpoint slides the Kilmarch sent out to support his talk, "Assessing the Effect of Antiretroviral Therapy on Risk of Sexual Transmission of HIV." Very useful and interesting compilation of data here. I'm not sure if the slides are public, so I won't republish them here, but I did want to highlight this slide on the hypothetical potential for ARV + Universal testing to dramatically impact the epidemic in South Africa:

Granted, this is highly hypothetical scenario (based on this modelling study) -- requiring a number of assumed phenomenon to be implemented without problem. But the entire set of slides highlights the potential for a combination of testing and treatment to be used as a powerful set of prevention techniques. I've said it once, I'll say it again: these are tried and true tools in our prevention knapsack -- and they seem to rely much less on the needs of behavioral change messages that I believe are often stigmatizing and highly problematic. Though certainly testing / treatment program implementations can come with their own set of problems (treatment adherence, questions over when to begin ARV treatment, etc.)

What we need to make this feasible is certainly generic equivalents -- ASAP. And certainly a rethinking of the "old school" approaches to prevention.