When to Start ART, need to redifine treatment protocol in India ?

[Guest guest]

Dear Forum Members,

UK HIV treatment guidelines currently recommend that starting HIV treatment

should be delayed until a person’s CD4 cell count has fallen to around 200

cells/mm3, or the development of HIV-related symptoms if this is sooner. Most

other HIV treatment guidelines have similar recommendations.

But doctors at the Sydney conference (The 4th IAS Conference on HIV

Pathogenesis, Treatment and Prevention) argued that HIV treatment should be

started significantly earlier. Indeed, one leading doctor said the question

should be when not to treat HIV rather than when to treat.

Researchers told the conference that there was accumulating and persuasive

evidence supporting the earlier initiation of anti-HIV treatment. Firstly, it

has been recognised that soon after initial infection with HIV, the virus causes

significant and sustained damage to lymphoid tissue in the gut.

Second, there is now good evidence that patients who started HIV therapy with a

CD4 cell count of 350 cells/mm3 are much more likely than those who delayed

starting treatment until their CD4 cell count was in the 200 cells/mm3 range to

experience a long-term strengthening of their immune systems to near-normal

levels.

Thirdly, there is accumulating data showing that a low CD4 cell count increases

an HIV-positive individual’s risk of developing serious non-AIDS-defining

illnesses, such as cancer, heart-disease, liver problems and kidney failure.

Prof Jim Neaton highlighted results from the SMART treatment interruption study

showing that patients who interrupted their therapy when their CD4 cell count

was 350 cells/mm3 were significantly more likely than those who took their HIV

drugs continually to develop serious non-AIDS-related illnesses.

New data from patients in the SMART study shows that there were important

differences in markers of immune activation between people in the continuous

treatment and treatment interruption arms.

Fourthly, the Sydney conference was told that starting treatment at 350

cells/mm3 rather than the currently recommended 200 cells/mm3 could

significantly reduce new HIV infections because fewer people would have

infectiously high HIV viral loads.

I had discussion with many treating physicians at Sydney who had the same

findings and my first hand treatment data and outcome of treatment is also in

tune with Sydney Conference results.

We may need to redifine our treatment protocol after latest research findings in

order to save many lives.

With Regards,

Dr Diwakar Tejaswi. MBBS(Gold Medalist); MCH; FCCP; Ph.D.

Medical Director, Regional AIDS TRaining Center and Network in India (RATNEI)/

International Health Organization

Patna, India

Email: diwakartejaswi@...

www.ihousa.org

Mobile: +91-9835078298

[Guest guest]

Dear MEMBERS of the FORUM

Re: /message/7669

The cut off to initiate HIV -ART at CD4 of 200 cells is due to financial and

administrative reasons. If the fourth IAS conference at Sydney finally

recommends 350 as the cut off, it is because medical therapeutics is dynamic - i

hope it is not due to pressures from the drug lords

My humble submission is the old public health adage ' a stitch in time saves

nine ' and start HIV-ART early to strengthen and or restore one's own immune

system at the earliest and of course keep non AIDS defining illnesses at bay.

The spill-off is that we make the individual less infectious at the earliest and

thus reduce the pool of global infection

DR M. MATHEWS

e-mail: <docmathews@...>

[Guest guest]

Dear Dr Tejaswy and friends,

Re: /message/7669

The cut of for starting ARV should be decided considering many real life issues

in the developing countries not just the experience of experts from the west.

1. We all know the morbidity of HIV disease will be lesser if ART is started at

350 but there are studies showing the mortality is not much deferent between a

cut off of 350 and 200.

2. The issue of side effects and sustainability of program on long term and

financial visibility are other issues. With the present regimen of

Zidovudine-(Stavudine)/ Lamivudine/ Nevirapine(-Efavirenz) there is a relatively

high drug induced morbidity many of them are by itself life threatening .Unless

we are very sure how effectively we can mange in a massive scale it is better

to delay treatment till before CD4 reaches 200( the current guideline is to

start ART before CD4 reaches 200 not below 200).

3. Another issue is we should change the first line regimen to

Tenofovir+Emtricitabine+Efavirenz which are less toxic, single day tablet. This

also can save 2 back bone NRTIS, and a patient review for increasing the dosage

of Nevirapine at 2 weeks and switch of regimen for patients on anti TB drugs. In

that case probably starting treatment at 350 will be a great option provided we

can address all the logistical issues of regular supply. Probably this will be

more important an issue WHO and NACO should consider than including free second

line treatment as part of the program.

The spill-off is that we make the individual less infectious will work only if

the ART program remains successful for a long period without significant

resistance and drug induced morbidity.

If we are successful in counseling HIV should not spread from any person who has

gone through testing. If it is not successful, ART is not going to be

successful, transmission will continue.

There are many reports of increase of incidence STIs from the west after the

advent of successful ART.

More than the drug it is the safe sexual practices going to make deference. Drug

therapy is unlikely to replace it.

Dr. Kidangazhiyathmana Ajithkumar

Trichur

e-mail: <ajisudha@...>