WHO Decision to Recommend Treatment for All With HIV an Easy One -- Now Comes the Hard Part

In the newspaper today -- and yes, we still do get it delivered (some habits die hard) -- is this headline:

Millions More Need H.I.V. Treatment, W.H.O. Says

It's true -- these updated guidelines say that all should be treated soon after diagnosis, regardless of CD4 cell count or whether they have symptoms.

Now, a certain non-ID doctor read the headline this morning, and asked me what the big deal is. After all, she's been hearing about our treating everyone with HIV here for years -- since 2012, if you want to be precise about it.

Even before that, in trendy San Francisco, the Department of Public Health in 2010 recommended treatment for all people with HIV regardless of CD4 cell count. Today this decision is paying big dividends in that city, with a decline in new HIV diagnoses probably linked to this policy in action.

Indeed, given the results of the START, TEMPRANO, and HPTN 052 studies, the WHO's decision to modify its recommendation is about as surprising as Jerry's telling George, Kramer, and Elaine that he wants to have lunch at Monk's.

(Not sure why I thought of that analogy. Must be hungry.)

The data are now so overwhelmingly in favor of universal treatment of HIV infection that I can only think of one subset of patients for whom therapy has not been proven to be beneficial. These are the rare "HIV controllers" with undetectable virus and normal CD4 cell counts even without treatment. My hunch is that it probably benefits them too, though this is still under study.

The challenge, of course, is putting the "treat-all" policy into action. In Sub-Saharan Africa, the UNAIDS estimate of the proportion of people living with HIV who have been diagnosed is only 51%. Obviously, the other 49% are not getting any sort of treatment unless there is a massive HIV testing campaign.

In addition, treatment of everyone will likely strain both human resources and medication supply, with an additional 9 million people eligible for treatment but no new funding source to pay for it. As such, there's an important statement in the guidelines about whom to treat if resources are limited:

Regardless of the epidemic profile and disease burden, priority should be given to people with symptomatic HIV disease or with CD4 count at or below 350 cells/mm3 who are at high risk of mortality and most likely to benefit from ART in the short term.

In other words, if you can't treat everyone, treat the sickest first -- they have much more to gain survival-wise than healthier people with HIV, so you definitely get more for your human and pharmaceutical investment.

But are clinical programs set up to do this? I suspect that with this recent WHO Guidelines change, most will operate under a "first-come, first-served" approach, offering treatment to everyone that shows up -- until medication supplies run out or the clinic gets overwhelmed. As my colleague Ben Linas noted years ago when studying AIDS Drug Assistance Program waiting lists, this is not the best approach to maximize impact with limited resources.

The change in the WHO Guidelines, unsurprising as it might be, makes good sense scientifically. Time for a different sort of science -- "implementation science" -- to figure out how to make it happen, and how to benefit people the most.

Back to Monk's.

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.