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Expert Commentary

Treat All. It's the Right Thing to Do.

Dr. Arthur J. Ammann discusses the benefits of early antiretroviral treatment for all HIV-infected individuals regardless of CD4 count or clinical status.

All HIV-infected individuals must be treated with effective antiretroviral therapy (ART) if the HIV contagion is to be brought under control. To do otherwise would serve only to sustain a costly and prolonged epidemic. In April 2012, the United States Department of Health and Human Services (HHS) revised its evidence-based HIV treatment guidelines to state, "ART is recommended for all HIV-infected individuals."(1) This is a simple, straightforward, and life-saving approach to HIV treatment and HIV prevention. The World Health Organization (WHO) has announced that it will not release its revised guidelines before June 2013. That's too long! Between now and then, millions of men, women, and children will be infected, become sick, and advance to AIDS. Children will be orphaned because of treatment delays.

Revise all international HIV treatment guidelines to recommend treating all HIV-infected women, children, and men, regardless of clinical status or CD4 count.

The current WHO treatment recommendations ignore clinical research studies that prompted other HIV organizations to recommend treating all HIV-infected individuals regardless of CD4 count or clinical status. One argument for the current WHO approach has an economic rationale--it will be more expensive to treat more people living with HIV. But delaying initiation of ART based on short-range cost estimates is shortsighted, and it ignores clinical data suggesting that the maximum benefit of ART results from early initiation of treatment. Early treatment reduces mortality, morbidity, and the onset of opportunistic infections such as tuberculosis; it decreases HIV transmission rates (treatment as prevention), decreases non-HIV-related diseases, lowers hospitalization costs, maintains CD4 counts, and preserves the lives of HIV-infected caregivers, thus reducing the burden of the vast HIV-related epidemic of orphans. The countless benefits of early ART will lower the unacceptable long-term economic and human costs of an uncontrolled HIV epidemic.(2,3,4,5)

Priority also must be given to identifying the millions of HIV-infected individuals who are unaware of their infection rather than waiting until they present to care with advanced disease. Further strides in controlling the HIV epidemic can be accomplished only if all individuals who have been exposed to or are already infected with HIV know their serostatus. It is estimated that more than 100,000 individuals in the United States do not know they are infected with HIV, and worldwide the number is estimated to be in the millions. Behavior change, use of condoms, male circumcision, prevention of mother-to-child HIV transmission utilizing combination ART, and treatment of HIV infection to reduce transmission to sex partners all have been proven to slow the rate of new HIV infections. Major HIV organizations such as the WHO, UNAIDS, HHS, the U.S. Centers for Disease Control and Prevention, and national ministries of health should recommend the highest standards of prevention and care and the maximal utilization of public health tools, including contact tracing, for controlling an infectious disease epidemic that has persisted much too long.(4)

What needs to be done now?

1. Revise all international HIV treatment guidelines to recommend treating all HIV-infected women, children, and men, regardless of clinical status or CD4 count.

2. Implement measures including contact tracing to identify the millions of individuals who do not know they are HIV infected so that they can be tested and, if infected, receive early ART. In turn, inform sexual contacts who have been exposed to HIV that they need to be tested, and treated if infected, and if not infected, to be counseled about how to remain uninfected.

References

  1. World Health Organization. Antiretroviral therapy for HIV infection in adults and adolescents. Recommendations for a public health approach, 2010 revision. Available at www.who.int/hiv/pub/arv/adult2010/en/index.html.
  2. Sterne JA, May M, Costagliola D, et al; When to Start Consortium. Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet. 2009 Apr 18;373(9672):1352-63.
  3. Severe P, Juste MA, Ambroise A, et al. Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Engl J Med. 2010 Jul 15;363(3):257-65.
  4. Brown LB, Miller WC, Kamanga G, et al. HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention. J Acquir Immune Defic Syndr. 2011 Apr 15;56(5):437-42.
  5. Granich RM, Gilks CF, Dye C, et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009 Jan 3;373(9657):48-57.