New World Health Organisation, HIV “when to start treatment” guideline
Released just a week ago on September 30, the World Health Organisation guideline on when to start antiretroviral therapy and on pre exposure prophylaxis for HIV, reflects recent trial data and best evidence based practice for all with HIV.
The guideline states that all persons with HIV, at any CD4 count, should be initiated on antiretroviral medication.
Whilst recent trial data, plus a number of previously published cohort data, has helped evidenced based guidelines be confident in their recommendation for treatment for all, international expert opinion has been discussing the likely benefit of early treatment for a number of years.
It is interesting to reflect that we have come full circle from the “hit early, hit hard” approach, which was shown not to work so well in the long term.
I have a few patients who for a range of reasons declined or avoided going on treatment in the early days. Whilst they were lucky enough to have been able to hold off from an immune point of view, they were doubly lucky to have avoided the toxicity of early treatment and the high chance of virological failure.
So why are things different now?
- Treatment is easier to take and less toxic, with fewer short and long term side effects and a very low pill burden.
- We are more aware of non AIDS complications of HIV infection and immunodeficiency
- We are perhaps better aware of the need for adherence and are certainly less tolerant of any loss of virological control, leading to quick action to minimise resistance (and better technology to monitor this)
- We have a number of different treatments in a number of drug classes which means we are less concerned about burning all options if something goes wrong with a regimen
- Most patients are engaged and informed in taking treatment properly and its benefits, which improves long term outcome
- Treatment as prevention is an accepted strategy
- The shift towards earlier treatment has been slow over the last few years and is not a knee jerk response
All that being said, I would only treat a patient who wants treatment and is engaged in medical care and in the need for being adherent to medication and medical follow up.
We should also be aware though that we really don’t know the long term complications of drug therapy. We are aware and monitor closely for renal, liver, bone toxicities, all of which can occur, but there is probably a lot going on that we can’t monitor or test for such as the brain.
The balance overall though is that the benefits of treatment outweigh the known risks.
Time will tell, as always. As I write this I am reminded of the recent shift from Efavirenz, which was the treatment of choice in guidelines for so many years, only to be relegated in recent times due to new data, 10 years on.