December 1, 2009
The past month has been a busy one when it comes to HIV/AIDS treatment guidelines. Revised U.S. guidelines were released on Dec. 1, providing an interesting counterpoint to recently updated HIV treatment guidelines from two other key groups: the World Health Organization (WHO) and the European AIDS Clinical Society.
On Nov. 30, the WHO revised its HIV/AIDS treatment guidelines for the first time since 2006. Perhaps the most noteworthy change to the guidelines, which are meant primarily for developing countries, is that the WHO raised its recommendation for starting HIV treatment from a CD4 count of 200 to a CD4 count of 350. That change may make as many as five million more HIV-positive people eligible for antiretroviral treatment throughout the world, WHO says. Of course, it also raises an important new question: If five million people living with HIV in resource-poor countries are already in need of medications, what will happen when millions more people are added to that waiting list?
Also among the revised recommendations is a more aggressive stance on HIV treatment for pregnant women. Whereas WHO's previous guidelines recommended that women with HIV begin antiretroviral treatment at their 28th week of pregnancy, the new guidelines say that they should begin taking HIV medications at week 14. In addition, the old guidelines were noncommittal on the issue of breastfeeding, WHO says; by contrast, the revised guidelines recommend that women continue taking HIV medications through the end of the breastfeeding period, which WHO suggests should last until the baby is 12 months old.
Another welcome change worth noting is that the WHO now recommends countries start phasing out Zerit (stavudine, d4T) -- a process that began long ago in the U.S., since Zerit is known to be the leading culprit of lipoatrophy (fat loss) among HIV medications, and has been tied to other side effects as well. The WHO recommends that countries turn to Retrovir (zidovudine, AZT) or Viread (tenofovir), two less-toxic alternatives to Zerit.
The European AIDS Clinical Society updated its own set of HIV/AIDS treatment guidelines just a few weeks ago (and for the first time since 2007). They differ from the new U.S. guidelines on the issue of when to start treatment: The European guidelines suggest that, among HIV-positive people with a CD4 count between 350 and 500, starting treatment is only recommended if that person is pregnant, over the age of 50 or has one of a range of specific health conditions, including hepatitis C coinfection, cardiovascular risk and cancer. (The revised U.S. guidelines, by contrast, recommend treatment for all HIV-positive people with a CD4 count below 500.)
What really sets the European guidelines apart, however (besides the fact that they're much easier to browse online), is how much detail they go into on the issue of HIV and aging. They include a host of prevention, testing and treatment recommendations for cancer, heart problems, bone disorders and other health issues that are growing more common among people with HIV as they get older.