U.S. guidelines, which previously suggested starting HIV treatment when CD4 counts fell below 350, have been revised to encourage people to begin when their CD4 counts are as high as 500. But guidelines committee members (researchers, clinicians and community activists) disagreed on whether to make the new recommendation “strong” or “moderate.”
Committee member Heidi Nass of the University of Wisconsin's HIV/AIDS program in Madison told POZ, “If evidence fully established the benefit of starting [at CD4 counts as high as 500], we'd be looking at an A-1 rating. Instead, some feel this change is too much, too fast, with too little [evidence], while others feel that the data [already] justify putting the early start option on the table, to be sorted through between an individual and a doctor. As my own HIV doctor likes to say, ‘They're just guidelines.'”
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While the European AIDS Clinical Society (EACS) still recommends starting meds at 350 CD4 cells or below, the guidelines now add that people who also have hepatitis, HIV-associated kidney disease or another organ illness should begin treatment when CD4s are as high as 500. The EACS guidelines also detail special HIV-treatment advice for people with heart disease and other medical conditions.
In the Developing World
The World Health Organization (WHO) issued a new set of guidelines suggesting all HIV-positive people in the world's poorer countries start treatment when their CD4 counts fall below 350. These recommendations replace the previous ones, which advised positive people with no symptoms to start meds when CD4s hit 200.
The new guidelines skirt some key considerations about when to start treatment. Two of these urgent issues:
Many Americans don't discover they are living with HIV until they get sick—often when their CD4 counts are well below 350. For them, the new numbers mean little. The biggest question remains how to encourage people to get tested and into care early, increasing their chances of survival and offering them a wider array of options for treatment.
Gregg Gonsalves, of the International Treatment Preparedness Coalition, says the new WHO recommendations could result in more people vying for the same pool of medication. There are not enough meds to go around already; treating all positive people with 350 CD4s could create further shortages for those who are critically ill. “Millions of people eligible for antiretroviral treatment under the old WHO guidelines—because they have clinical symptoms or CD4 counts below 200—still cannot get access to this lifesaving medication,” Gonsalves told POZ. “While the new WHO guidelines make sense clinically, those who are sickest should remain the first priority for AIDS treatment.”
Shifting the Starting Lines
Late last year, U.S., European and global HIV treatment guidelines all included new recommendations for when to start HIV meds. The trend is to begin earlier, but specifics vary—and questions remain. Below, a recap.