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April 4th, 2010
San Francisco Public Health: Treatment Recommended for All with HIV
Could there be anything more interesting than the start of the baseball season?
Maybe, because this is quite something:
In a major shift of HIV treatment policy, San Francisco public health doctors have begun to advise patients to start taking antiviral medicines as soon as they are found to be infected, rather than waiting — sometimes years — for signs that their immune systems have started to fail.
Yes, the field is heading in this direction, but thus far no one has had the guts actually to recommend universal treatment as policy.
In the early 2000s, I often referred to this review by my friend and colleague Keith Henry for why we might want to hold off on starting treatment for as long as possible. How did we get from there to a policy to treat everyone? Selected highlights:
- 2006: SMART study stopped — intermittent therapy is worse than continuous treatment, including the risk of non-AIDS complications. In other words, toxicity of ART notwithstanding, untreated HIV is worse.
- 2006: One-pill a day treatment (TDF/FTC/EFV) approved. It wasn’t and still isn’t for for everyone, but it definitely was the next chapter in making treatment much easier to take, a far cry from the handful of toxic pills we prescribed in the late 1990’s.
- 2007: SMART “naive” analysis is presented at the Sydney IAS meeting, (link is to published paper) showing that even for those starting SMART with high CD4’s but not on therapy, intermittent treatment was worse.
- 2008: The famous “Swiss Statement” proclaimed that patients with undetectable HIV RNA on treatment cannot transmit HIV to others. (If you read French, here is the original.) A series of studies — some in serodiscordant couples, some population-based, some just mathematical models — have followed, all essentially demonstrating that HIV treatment is more effective than any other preventive strategy we currently have.
- 2009: NA-ACCORD is presented at CROI, concluding that deferring therapy until the CD4 falls below 500 cells is associated with a nearly two-fold increased risk of death. The paper is then published in the NEJM, adding credibility to the statistical gyrations required to do such an analysis.
That’s not a comprehensive list, of course, but these and other data led to a change in the latest HIV treatment guidelines, which despite raising the CD4 threshold for starting therapy, still do not go as far as the proposed San Francisco recommendations.
Is their room for uncertainty? You bet:
James D. Neaton of the University of Minnesota School of Public Health, contends that a rigorous, randomized clinical trial is needed to show whether early intervention works. The risks of early treatment — giving powerful drugs to people at low risk of disease — – could outweigh the “modest predicted benefit,” Dr. Neaton wrote in an e-mail message. “That is why we do randomized trials.”
Dr. Lisa C. Capaldini, who runs an AIDS practice in the Castro district, also has strong reservations. “H.I.V. behaves differently in different people,” she said. Although Dr. Capaldini recognizes that today’s drugs are a vast improvement over earlier therapies, the program, she said “is not ready for prime time.”
San Francisco has always had a distinctive role in the history of the HIV epidemic.
Why should now be any different?
Paul E. Sax, MD
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