Everyone with HIV who is prepared to take antiretroviral treatment should receive it, regardless of CD4 cell count, new draft British HIV Association (BHIVA) treatment guidelines recommend. The new draft guidelines say that anyone living with HIV who understands the commitment of treatment and is ready to start should receive treatment. The change – from a recommendation to start treatment before the CD4 cell count falls below 350 cells/mm3 to treatment for all – follows the results of the START trial, a keenly awaited international study of when to start treatment.
The START study showed that starting treatment at a CD4 cell count above 500 cells/mm3 reduced the risk of death or serious illness by 53% compared with waiting to start treatment until the CD4 count fell to 350 cells/mm3. Although the absolute risk of death or serious illness was small – 3.7% of people in the deferred treatment arm became seriously ill or died, compared to 1.8% in the immediate treatment group over three years of follow-up – the BHIVA guidelines committee concluded that the evidence now supports offering treatment to everyone prepared to take it.
Two other recent studies, the Temprano study and HPTN 052, also influenced the decision to offer treatment to all. Temprano, a study conducted in West Africa, showed that starting treatment at a CD4 cell count above 500 reduced the risk of serious illness and death by 44% when compared to starting treatment at lower CD4 counts.
The HPTN 052 study, carried out in sub-Saharan Africa, India, Brazil, Thailand and the US, showed that early treatment – starting at a CD4 cell count between 350 and 550 – reduced the risk of clinical illness by 40% but did not significantly reduce the risk of death when compared to starting treatment at a CD4 cell count below 250 cells/mm3. HPTN 052 also showed that earlier treatment reduced the risk of sexual transmission of HIV by 96%. That finding formed the basis for BHIVA’s previous recommendation that anyone living with HIV should be enabled to start treatment if they thought that it could reduce the risk of HIV transmission – and that all people living with HIV should be informed by their doctors of the evidence linking antiretroviral treatment to a reduced risk of transmission.
The updated guidelines continue to emphasise this evidence, and recommend that doctors should continue to discuss the potential for reducing transmission with all people living with HIV. People with HIV should be assessed for readiness to start treatment after diagnosis, but treatment initiation should only be considered urgent for people with Aids-defining infections, serious bacterial infections or a CD4 cell count below 200 cells/mm3. People in any of these categories should start treatment within two weeks, the guidelines recommend.
Recently infected people – anyone diagnosed with primary HIV infection within 12 weeks of a previous negative test – should be encouraged to start treatment immediately in order to improve immune recovery, limit the size of the viral reservoir and limit the potential for onward transmission at a time of very high viral load. Anyone diagnosed with primary HIV infection who has a CD4 cell count below 350 cells/mm3, an Aids-defining illness or neurological symptoms should also be encouraged to start treatment as soon as they can. Other people diagnosed soon after infection should be invited to consider starting treatment in the same way as any other person diagnosed with HIV – when they feel ready.