BioEd Online

The World Health Organization says it will recommend that everyone with HIV be given antiretroviral (ARV) drugs as soon as possible after diagnosis – following a series of convincing trials proving the benefit of early treatment.

The agency discussed widely-anticipated plans to change its guidelines at a satellite session at the annual meeting of the International AIDS Society (IAS) in Vancouver, Canada, where the latest impressive results from trials of ARV treatment were also announced.

“Given the very encouraging results we’ve heard at this conference, we’re working towards a recommendation to provide treatment to all people that are HIV positive, early,” says Gottfried Hirnschall, director of the WHO’s HIV/AIDS department. The update to the agency’s guidelines is expected to take effect in December.

The change would raise the number of people eligible for the drugs from 30 million to 36.9 million, Hirnschall notes; the WHO’s current guidelines recommend immediate treatment for young children, pregnant women, and people with other infections (such as tuberculosis); or, more generally, when any HIV-infected person’s ‘CD4’ cells — part of the immune system — fall below a particular threshold.

Hirnschall says the scaled-up response would require some US$30 billion over the next five years, with half of that going towards testing for HIV and drug treatment.  But the immediate priority is finding and testing people with HIV, experts warn. “Only 50% of those people know their status,” Hirnschall says — and of those, only 40% are estimated to be currently accessing treatment.

Treatment as prevention

he WHO’s plans were bolstered by results from two long-standing trials into ARV treatment, released on 20 July at the IAS conference.

One, the HPTN 052 study, had already shown in 2011 that immediately treating the infected partner of a couple cut the risk that the person would transmit their virus to the uninfected partner by 96% (compared to a group who did not receive immediate treatment). The evidence was so strong that the study’s design was changed to offer treatment to all participants. Four years later, longer-term results are almost as impressive, researchers revealed, with risk of HIV transmission in those receiving early drug treatment reduced by 93%.

Another, the START trial, had reported interim results this May that early drug treatment of people with HIV cut their risk of serious illness or death by 53%. The full results, presented today, show a greater drop of 57%.

“Antiretroviral treatment works,” says Myron Cohen, director of the Institute for Global Health & Infectious Diseases at the University of North Carolina at Chapel Hill, who led the HPTN 052 trial. “The ‘treatment as prevention’ movement can have great confidence and feel comfortable in endorsing this as a public health strategy,” he says. Cohen is confident the intervention can reduce all routes of HIV transmission. “Observational studies show it should work in men who have sex with men and we’re doing a study now looking at intravenous drug users,” he adds.

“For a long time there was the tension between whether you should focus on preventing HIV infection or treating HIV infection, [but] HPTN 052 showed that treatment is prevention,” comments Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the US National Institutes of Health, which funded the trial.

And the START results, he adds, show a double-benefit of early drug treatment. “The data say overwhelmingly that you’re benefiting from decreased transmission and you’re benefiting the person that’s getting treated. That’s pretty solid stuff.”