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?
As a non-medical doctor, in my 26 years of watching HIV treatment (dating back to the lethal AZT-only therapy of the late 1980s) I have learned that each individual must experiment with what works for them rather than blindly follow a doctor's dogma.
This new research is just another flip-flop from previous advice and it does not provide any reason (other than weak statistical significance and speculation) why the previous advice was right or wrong. Perhaps this advice makes sense for people unable to intelligently work with the medical system, but it is bad advice for anybody with any intelligence to blindly follow.
As another non-medical PhD, I'd have to disagree with the above - the new research is not "just" a flip-flop - while we can debate the significance of the statistical findings, it is, in fact, grounded upon empirical data that was lacking when prior recommendations were made. The point Trevor makes about putting off side effects doesn't seem as big a deal as it once was - many individuals (and *some* of this can be determined by genotyping the individual's virus) can go on relatively simple regimens with low rates of side effects, and these new studies suggest that the longterm prevalence of side effects may be lower if ART is begun with a CD4 count above 500 - if this data continues to be held up, it may be that a higher risk of side effects but an immediate start to meds will still yield a lower lifetime chance of poor medication reactions. As many commentators on this move have pointed out, these are decisions every patient-doctor dyad should make in collaboration.
That said, it's irresponsible and, frankly, mean, to criticize those following science-based medical advice as lacking intelligence and as blind followers. That misrepresents both the data behind this move, as well as the good intentions of both providers and patients.