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May 5, 2010

START Wars

by Tim Horn

There is a dearth of data from randomized clinical trials to demonstrate that the benefits of starting treatment when the CD4 cell count is above 350 outweigh the potential risks. Despite this paucity, a groundswell of support for early treatment is already growing.

As mentioned earlier, the San Francisco Department of Public Health (SFDPH) is now recommending ARV therapy be started as soon as HIV is diagnosed, regardless of the person’s CD4 cell count. Project Inform quickly followed suit, noting the potential personal and public health benefits that may come from early HIV treatment. Though Project Infom has quietly changed one its more controversial initial recommendations, Project Inform’s position statement continues to read as a strong endorsement for early treatment. 

Bob Huff, a member of the AIDS Treatment Activists Coalition (ATAC), supports Project Inform’s original April 13 statement. “Based on what I understand about the evidence, and on what I understand about the potential benefits of treating HIV whenever it is diagnosed, I agreed with the position PI has taken,” Huff says. “I commended them for it because other AIDS organizations have avoided—or even actively resisted—supporting programs to greatly expand testing and treatment in their cities. I think PI understood it would be controversial but chose to make the statement anyway, and in doing so, I think, have showed some welcome leadership.” 

Huff adds that immediate-treatment-for-prevention is a “reasonable approach” in an area like San Francisco, where the epidemic affects mainly gay men and where there has been “significant progress in expanding treatment access, which may have resulted in lowering community viral load rates. [Given results to date,] it makes sense [that public health officials] would press forward to try and achieve even more success. The potential payoff for the campaign would be halting the spread of new HIV infections in the area—an amazing outcome. Because the upside is so profound, it’s necessary that they try to achieve that goal.”

Mark Milano, another ATAC member and an activist with ACT UP New York, sees things differently. “I was unhappy with the simplistic advice the PI paper gave,” he says. “Unlike [deceased Project Inform founding director] Martin Delaney's vision of empowering people with HIV to take an active part in their health care decisions, PI just said, ‘We looked at the data, and we think you should start at 500.’ There was no attempt to educate people about the lack of data, nothing about the split on the DHHS panel, nothing about the ongoing debate over when to start. That’s not the approach I think Marty would have taken—he would have respected people with HIV enough to give them all points of view so they could decide for themselves.”

Milano also remains skeptical of the test-and-treat approach to combating the ongoing spread of HIV. “If these decisions were motivated by epidemiologic concerns—and I hope they weren’t—I disagree [with them]. Urging [people to start] treatment at higher CD4 counts when we don’t know the long-term effects, in an attempt to lower community-wide transmission rates [of HIV], does a real disservice to individuals making this life-changing decision. Especially if we don’t tell them [that protection of public health is] part of the motivation [for the recommendation].”

Collins adds: “An undetectable viral load on an individual level reduces the risk of transmission—this is supported by the data. But rolling out early treatment as a public health policy is different. An individual taking treatment primarily has to derive personal benefit, given that they face an individual risk from treatment. The discussion for individual treatment and public health cannot just be lumped together.”

Pages: 1 | 2 | 3 | 4 | 5

Search: START, randomized studies, HIV treatment, antiretroviral therapy, Project Inform, Bob Huff, Mark Milano, Simon Collins, controversy


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  comments 1 - 15 (of 21 total)     next > >>

G-B, USA, 2010-06-22 13:06:36
SMART is not about the best treatment for individuals, but lowering the community viral load, so transmissions decrease. It assumes poz people are transmitting it, rather then untested. It's unethical. And of course they are touting the health benefits of starting early, to convince people. After 5 years with no meds, my viral load is still at 200 and my CD4s are high. Why would I start meds that in the long run may prove to be worse for my health, after being on them for 40 years???

Frederick Wright, Tampa, 2010-05-25 11:35:00
This debate about when to start or what is a safe dose of ARV's for people is surprising that not one of the National AIDS/HIV groups from Housing Works, NMAC, AIDS ACTION , The AIDS Institute, NAPWA or State AIDS Leaders AKA employees of the States are taking a stand or position. Where is the Leadership? They are waiting I guess to inform the people they serve when it is safe to speak and act. Silents equal Death and clearly new leadership is needed within these so called AIDS Non Profits.

Tim, Pittsburgh, 2010-05-19 17:05:16
Since when is a Community Health Outcome the goal of a individual's treatment plan?

Christopher, , 2010-05-19 02:59:11
"If patients are ready and willing, go for it !!! Promote a health immune system!"--not much of an argument there; sounds more like a high school cheerleader or an advertising exec than a real doctor. This disturbs me. 20 years from now, are some of those patients going to have kidney damage who might have avoided with, potentially, ten fewer years of HAART?

Christopher, , 2010-05-19 02:57:28
(cont.) "Delayed western blot positivity,"--is that important?--"undetectable viral loads and CD4's 800-1500." Your patients will, now, never know how many med-free years they would have had, which is sad. I've had HIV for six years now and have done fine without meds; can you give me an argument why taking HAART these six years, and counting, would have improved my life?

Christopher, , 2010-05-19 02:51:41
Christopher G--I'm surprised at your statement. You write "I try to start all of my new (acute) HIV patients on HAART - all have done very, very well"--most of them would have done very, very well even without HAART; we'll never know, now, for how long--"and I haven't seen any negative outcomes."--is this meaningful? What kind of negative outcomes were you likely to find? The arguments against early treatment come from the unknown effects of decades on HAART. Get back to us in 20 years, ok?

Matt, Raleigh, NC, 2010-05-15 13:31:55
Article says nothing of VL in respect to starting treatment. I was recently diagnosed. My cd4 count is 366 and undetectable VL w/o treatment.My doc tells me my body is controlling the virus and meds are not necessary right now. With the information in the article and comments below, I am wondering if I should start treatment sooner rather than later.Docs tell me that treatment is not necessary til VL over 100,000 copies.But not excited to wait to get sick to start treatment.

Frederick Wright, Tampa, 2010-05-15 09:24:18
Tim, I am in agreement that folks should start meds when they choose in agreement with their Doctor. And Thank God for all the people before me that took these experimental drugs, some died, some live. Which makes these drug better in science and community. The problem for me is what is the right safedose, for many say take them like they are prescribed, while saying ever one is different. Does not make since if all are different for all to take the same dosage. This is not about when to start

OriginalTim, , 2010-05-14 10:32:50
I fully support starting meds as soon as possible. I took this decision as a life changing event. I was tired of waiting till I got sick to start meds. Every day waiting on my labs to come back was an extra day of unneeded stress. The meds are safe now so I started when my cd4 was well above 500 and I have not been sick a day since, not even a cold. Furthermore, the stress of waiting on my health to decline has been eliminated. I can now live my life to the fullest.

Rosetta, Buffalo, NY, 2010-05-12 12:37:46
We have been seeing for years the physical challenges from long term use of HARRT. I think this is just a way to prevention the transmission of HIV, so that's what they should say it's about!

Frederick Wright, Tampa, 2010-05-12 10:56:09
Yes, a piece of the truth would be nice and I am very happy my Faith is not in a Study or a Doctor for the confusion is in the term experts. Project Inform is an expert at data, which according to the National Physician Alliance can be mis-leading by Doctors signing off on anything that the Drug Companies want them to do. The other confusion is that Doctors are the experts in handing out pills, however the HIV person is the expert on taking pills. Craig thanks for addressing this debate.

Craig, Orlando,fla, 2010-05-11 14:14:55
Well to tell the truth. I am still undecided on the whole matter! I understand that the risk of starting early would be the potential side effects of long term meds! Now on the other hand it could be that the side effects are worse in folks whom wait till the below 300. It could be that since the virus is so rampant that the meds effect the rest. So I think instead of all this crap about who said what and when. We should wait for the results of the START study! Then make a choice with your doctor

Frederick Wright, Tampa, 2010-05-09 13:28:40
Again out of date and Tim Horn is reacting not leading. I am not suprized that this conversation is out dated compared to Europe where Titration of Drugs is a treatment option. Most people here do not know or understand Titration of Drugs and again the lack of leadership in the USA is so riddled with false information. A study that is short sided. Concerning Mr Picket comment about money, Why are the Drug Companies not coming down in price after 10 years of having a cash pig from Medicare.

Frederick Wright, Tampa, 2010-05-08 09:39:13
The sad thing about TNT is that it adresses a small part of treatment focus at pills, where nutients and life stye changes should be adressed, like if t-cells are below 500 stop using cocaine and eat well, and find a loving mentor that will help you think and act in your community. Concerning Mr Picketts concerns about money it would be less expensive to treatHIV people and notAIDS with huge hospital bills then a 50 cent drug a month that PHARMA sells to our Goverment for thousands dollars

Vanessa Anderson, San Diego, 2010-05-06 11:16:03
I chose to participate in the study and started my antivirals at a tcell count of 600. It has changed my life. I wasn't completely aware of how tired I was before and what a struggle everyday really was i had been doing for such a long time. My viral load is now undetectable and my tcells are at 950. I have more energy and although it can be a pain in the butt to remember to take them everyday my quality of life is back to were it was before i was infected.

comments 1 - 15 (of 21 total)     next > >>


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