The START (“Strategic Timing of AntiRetroviral Treatment”) study was a randomized, controlled clinical trial designed to more clearly define the optimal time for HIV- infected individuals to begin antiretroviral therapy. The study was stopped early (May 2015) and showed that starting antiretroviral therapy early prevents a combination of outcomes that includes AIDS events (such as AIDS-related cancer) and serious non-AIDS events (major cardiovascular, renal and liver disease, non-AIDS cancer, and death not attributable to AIDS).
In India, currently we start ART at a CD4 count
Hi, I think it would be a great decision. The WHO ART guidelines now recommend a CD4 count of 500 cells/ul ). Many studies have showed the benefit of a Test and Treat strategy. The major challenge remains the ability of the health care system (people, infrastructure and cost) to reach a much higher number of ART eligible patients. Regards.
Links: WHO guidelines
http://apps.who.int/iris/bitstream/10665/179870/1/9789241508926_eng.pdf?ua=1&ua=1
Links: Test and Treat
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520051/
http://cid.oxfordjournals.org/content/52/6/801.extract
http://www.fidssa.co.za/images/Graeme_Meintjes_-_A_POLICY_OF_TEST_&_TREAT_REGARDLESS_OF_CD4_COUNT.pdf
Dear Dr Naseem,
I notice that you are from South Africa. I am not sure how similar are the social dynamics that givern HIV adherence in the 2 countries.
In India, the issue is something else. The failure rate (default of therapy) is between 2-4% per year. Majority of them are asymptomatic patients who are being treated for a concept, namely; "Though you are asymptomatic now, take these medicines now and your life will be prolonged by many years". The concept is in the Doctor's mind and not all patients buy into the same concept despite counselling. Illnesses that are treated on concepts (eg. Hypertension) where patients are predominantly asymptomatic, are plagued by poor adherence. In hypertension the adherence is sometimes just about 50%. In HIV too, though 4% leave treatment fully, a much higher percentage toy with the idea of default and intermittent defauly (say for a few weeks) is done by over 10%. In a country like India, there are many options sold in the name of "curing" HIV and people often stop their ART and go for this alternate option. This situation is a bit peculiar for India and might not be so prevalent in countries like UK and USA.
If "X" number of people take ART with CD4 being 350 while initiating therapy, the number will shoot up to nX when the bar is raised to 500 or above (n being 2-3 or higher). So the deafulters in community increase from 0.04X every year (with resistant strain) to 0.04nX. The results are cumulative over time. In 10 years the number of resistant strain shoots up exponentially.
I have my own reservations about asymptomatic patients of HIV with high CD4 sticking to a highly disciplined regime. So, which of the 2 is the better option?
regards
Hello Shankar, great way to express the notion of a population with strong beliefs in alternative medicine and "HIV total cures", in the Southern of Mexico is lightly similar and we have the same situation. All in all, I will stand for the early initiation of the HAART, but your point is a very valid one and hope to see a economic and long term projection studies on the issue of resistance generation.
I don't think that you will get a reasonable answer as these will be opinions. One possibility is to construct a mathematical model of HIV dynamics, treatment, and resistance, and ask that question. It will be a model, though. Ultimately, a similar trial will be needed in countries like India where compliance may be of an issue to provide definite answer.
Dear Shankar Subramanian
It's possible that early initiation of antiretroviral treatment may expose to increasing viral resistance, and early treatment failures. We will have the answer to this concern when the results of ongoing studies in Zambia and South Africa will be published [1, 2].
It is also important to note that the major route of HIV transmission is sexual, more so in poorest areas. Immediate ART initiation thus favorably impacts not only the individual, but also all their sexual partners, providing tangible public health benefit.
The purpose of an early initiation of antiretroviral therapy is therefore not only improve the quality of life of people living with HIV but also to prevent HIV transmission. Thus, we can probably have a lower prevalence of HIV infection.
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1. Iwuji CC, Orne-Gliemann J, Tanser F, et al. Evaluation of the impact of immediate versus WHO recommendations-guided antiretroviral therapy initiation on HIV incidence: the ANRS 12249 TasP (Treatment as Prevention) trial in Hlabisa sub-district, KwaZulu-Natal, South Africa: study protocol for a cluster randomised controlled trial. Trials 2013;14:230.
2. Hayes R, Ayles H, Beyers N, et al. HPTN 071 (PopART): rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment - a study protocol for a cluster randomised trial. Trials 2014;15:57
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