March 27, 2012
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
From the key "What's New in the Guidelines" section of today's Department of Health and Human Services update:
ART is recommended for all HIV-infected individuals. The strength of this recommendation varies on the basis of pretreatment CD4 cell count.
This recommendation replaces a rather confusing categorization on when to start ART that, not surprisingly, was widely misinterpreted -- fortunately, it now has been retired in favor of this much clearer statement.
The main reasons for the change were 1) greater appreciation of the dangers of uncontrolled viral replication (see this paper, for example) and 2) the data from 052 confirming the powerful effect HIV treatment has on preventing transmission.
My personal experience is that the latter has turned out to be the main driver of early HIV treatment in clinical practice. When my patients with high CD4 cell counts are informed of this benefit, they have almost uniformly become more motivated to start treatment.
Perhaps that's no surprise, but it's important to remember that what was widely considered a "public health" benefit of ART seems to have personal benefits for most individuals as well. People prefer being less contagious to others.
Now let's see if we can make this treatment happen -- it sure will be a challenge, as lots of people with HIV are not even in care, and won't be having these discussions with their providers.
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.
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