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World Health Organization to recommend early treatment for everyone with HIV

Public-health specialists convinced by weight of evidence from several large trials.

A patient with HIV is given a month's worth of medication at the Thyolo District hospital in Malawi. The WHO is to recommend that everyone with HIV get early drug treatment. Credit: Marco Longari/AFP/Getty Images

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

The agency discussed widely anticipated plans to change its guidelines during a 19 July satellite session at the annual meeting of the International AIDS Society (IAS) in Vancouver, Canada, at which impressive results from several ART trials 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 who are HIV positive, early,” says Gottfried Hirnschall, director of the WHO’s HIV/AIDS department. The updates are expected to take effect in December.

The change would raise the number of people who are eligible for the drugs from 30 million to 36.9 million, Hirnschall notes. At present, the WHO recommends immediate treatment for young children, pregnant and breast-feeding women and people with certain types of infection, such as tuberculosis. It also urges treatment for any person with HIV whose CD4 cell count — an important indicator of a healthy immune system — falls below a defined threshold.

Hirnschall says that carrying out the scaled-up response would require some US$30 billion over the next 5 years, with half of that going towards testing for HIV and drug treatment. But the immediate priority is to find and test people with the illness, specialists warn. “Only 50% of those people know their status,” Hirnschall says — and of that group, only 40% are estimated to be currently accessing treatment.

Treatment as prevention

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

One trial, known as HPTN 052, had already shown in 20111 that treating the HIV-positive partner in a couple immediately after diagnosis cut the risk that the person would transmit the virus to the healthy partner by 96% (compared with couples who did not receive immediate treatment). The evidence was so strong that the study’s design was changed to offer treatment to the control group. Four years later, the results are almost as impressive, researchers revealed, with the risk of HIV transmission reduced by 93%.

START, another clinical trial, reported interim results this May2, demonstrating that early drug treatment of people with HIV decreased 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 that 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 — 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 in Bethesda, Maryland, which funded the trial.

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

References

  1. Cohen, M. S. et al. N Engl J Med 365 493-505 (2011).

    PubMed  PubMed Central  ADS  CAS  Article  Google Scholar 

  2. Lundgren, J. D. et al. N Engl J Med http://dx.doi.org/10.1056/NEJMoa1506816 (2015).

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The HIV epidemic can be stopped 2015-Jul-07

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Treatment is prevention 2011-Jun-07

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Senthilingam, M. World Health Organization to recommend early treatment for everyone with HIV. Nature (2015). https://doi.org/10.1038/nature.2015.18017

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