HIV Treatment Strategy
For a fair amount of time during the 2000s, the debate over when to start antiretroviral therapy was frequently referred to as a "pendulum," as dueling studies stoked the debate over the value of early initiation (to reduce viral load and stave off immune decline) versus its risks (namely, the toxicities of HIV medications and the risks of emergent resistance due to imperfect adherence).
2012 may prove to be the year that the pendulum finally stopped swinging.
A growing number of studies (and the guidelines based on their findings) support HIV treatment initiation at higher and higher CD4+ cell counts. There may be none more important than the landmark HPTN 052 study, which last year stunned the clinical and research communities by revealing a 96% reduction in HIV transmission risk among serodiscordant couples in which the HIV-infected partner initiated treatment early and maintained virologic suppression.
At this year's International AIDS Conference, new HPTN 052 data were unveiled that demonstrated benefits for the HIV-infected partner as well: significant reductions in comorbidities and significantly delayed mortality among those who begin HIV treatment with a CD4+ cell count above 350.
It is findings such as these that make geniuses out of people such as the San Francisco public health officials who instituted a "treat everyone with HIV" policy back in 2010. That program has, of course, been strikingly successful. While antiretroviral therapy should never be prescribed blindly or without taking into account a patient's capability to take medications safely and adhere to them, the reasons to hold off on at least recommending treatment initiation to all patients appear to be dwindling.