Re: When to Start ART: Two Major Cohort Studies Published

[Guest guest]

Friends,

Re: /message/10306

I feel time has come when NACO should also revise the guidelines as

per DHHS etc.

Also I want to bring to the notice of those who matter that at times

patients on ART and doing well in terms of clinical and immunological

presentation(from ATR Centers) are advised to stop the ARV's. I have

some examples but I do not want to embarrass anyone. If needed proof

it can be given, but idea is to send a clear message to those who manage ART

centers and my suggestion should better be taken in right spirit.

The other point I want to emphasise again is that there is no harm in

taking help of experienced Drs, specially till the time

local MO of ART's are not trained when decisions like second line

requirement are to be taken rather than postponning to refer such

cases till the time of their training.

Dear NACO,meri baaton par dhayan dein--naaraz na hoyein

Dr.Rakesh Bharti

--

Rakesh Bharti MD,AAHIVS,

BDC Research center,

27-D,Sant Avenue,The Mall,Amritsar.

Punjab,INDIA143001.

TEl-91-183-2277822;91-183-2278522

e-mail: <rakesh.bharti1@...>

[Guest guest]

Dear forum,

/message/10306

yes these studies and few more of this kind are being discussed in the

recent days. But it is too early to jump into conclusions on this.

Now it is rather clear that suppressing HIV early is good for survival. But

there are many more questions like

what is the prevalence of OIs

what is the chance of drug induced morbidity,

what is the impact of IRIS,

what are the drugs?

How good the adherence can be in the community?

How prepared is the community and system?

In the mail Dr Ragesh mention about the incompetancy of some ART doctors

Yes it is a fact and now we are delaing with too young (3rd) generation HIV

doctors who are thinking about mass casual leave as the first measure to

pressurise employers for a slary hike!

So going directly to start current ART for all at CD4 350/ 500 in India may not

solve the problem.

This will only lead to more pressure on ART centers, more morbidity, more side

effects, more drug failure and failure of the system.

One of the things possibly we should think is to go for a less toxic and

complicated regimen like Ten+ emtricitabine+efavirenz as the first line and

reduce the incidence of drug induced morbidity and complications of regimen

mangement and pill burden.

This single tablet a day therapy will help in large scale ART mainstreming

through public health care system. This will aslo help us in giving more stress

on more effective and scientific PPTCT program using better drugs.

Also staring at CD4 350 will not be a big issue as pill burden is low. Also this

will reduce incidence of OI including TB, OI induced problems is adherance,

Bactrim induced problems etc. Massive scale

up will help in reducing the unit price . Also this may help in eventually

integarte ART into public health care system-if it survives that long.

I know it is a dream -- In malayalam- " entoru nalla nadakkatha swapnam "

" what a nice impossible dream " .

But it is impossible to dream. we never even dare to dream about Universal

access in early 90s.

Dr Ajithkumar.K

--

Dr Ajithkumar.K

Asst Professor In Dermatology and Veneriology

Medical college Chest Hospital

MG Kav,Trichur, Kerala ,India

Ph 04872333322 (res)

9447226012

e-mail: <ajisudha@...>

[Guest guest]

Dear Dr Bharti,

Re: /message/10309

In your mail you mentioned " at times patients on ART and doing well in terms of

clinical and immunological presentation(ATR Centers) are advised to stop the

ARV's. and I have some examples but I do not want to embarrass anyone " .

If someone is giving erroneous advice that person needs to be corrected. This

is not a matter of embarrassment, and not reporting such matters for corrective

action can be construed to amount to abetment.

I would strongly advise you to take some action.

Regards,

Lt Col (Dr) Anil Paranjape, MD Pune

e-mail: <anilvparanjape@...>

[Guest guest]

Dear members

/message/10306

I agree with Dr.Ajithkumar. We should take his advise seriouly.

Inorder to reduce morbidity and mortality rate in India We need to advocate ART

initiation for the PLHIV at CD4 count 350 level.

 

All the dreams can happen one day, but it should happen very soon inorder to

save millions of people in our country, for that needs for change of treatment

policy and system.

As our new UPA Government headed by Econimist Dr.Manmohan Singhji have to think

and act immediately.

 

Yours in Solidarity

Rama Pandian

Founder/President

Tamilnad Network of Positive People

70/269, Labour Colony, Guindy

Chennai- 600 032.

Mobile : 094440 40469

e-mail: <tnpluz@...>

[Guest guest]

Dear all,

/message/10306

It is interesting to see that there are various studies to show when

ART should be started. Thank you for sharing this information.

I would like to add whichever CD4 count NACO/ WHO agree upon, the

ultimate decision should be if the patient is ready to start ART.

I see that even in the best of ART centers across the country, many

times patients are not consulted before they start ART.

I think to ensure adherence and also from a human rights perspective;

I think a patient needs to be " in " on the discussion of how ready they

are emotionally even if their body is ready.

I think there should be a guideline for this even if the patient is

illiterate or from a rural background. Every effort must be made to

educate the patient before they start ART rather than the counsellor

having to explain that they are started on life time drugs after

starting it.

Thank you,

Magdalene

Director

Center for Counselling

Chennai

e-mail: <magdalene.jeyarathnam@...>

[Guest guest]

 

Dear Forum Members,

 

Re: /message/10306

 

In March 2009, a delegation from AIDS Healthcare Foundation – t Fisher,

Dr Saavedra, Ms Terri Ford, Zoya Shabarova and Dr. Chinkholal Thangsing,

Asia Pacific Bureau Chief met key officials from WHO and UNAIDS in Geneva to

advocate for revising WHO Guidelines for CD4 count Treatment Initiation

Threshold.

The delegation advocated the need to ensure uniform standards across the globe.

The following were the officials with whom AHF delegation met in person and

shared our concerns. The delegation was given an opportunity to present the case

and assured early action in this regard.

 

1. UNAIDS: Barbara De Zalduondo – Chief Program – Priorities Support

Evidence, Monitoring and Policy department.

2. UNAIDS: Karungari Karusa Kiragu – Senior Preventive Adviser –

Programmatic Priorities and Support Division, Evidence, Monitoring and Policy

Department.

3. WHO: M De Cock – Director Department of HIVAIDS.

4. WHO: Dr.Ying Ru Lo – Coordinator Prevention in the Health Sector,

Department of HIVAIDS.

5.  WHO: Amolo Okero – Technical Officer, Department of HIVAIDS.

 

Also, in order to highlight this issue, we had submitted an abstract at ICAAP

2009 which has been accepted.

 

AHF Advocates Revising WHO Guidelines for CD4 count Treatment Initiation

Threshold

Ford T.1, Ganesan M. 2, Mohanty N.2, Thangsing C. 1

1AIDS Healthcare Foundation 2 AIDS Healthcare Foundation/ India Cares, Asia

Pacific Bureau; 9th ICAAP, 19-13 August, 2009

 

Issues:  Based on a growing body of evidence supporting earlier treatment, a

number of health agencies in developed countries have updated their guidelines

to recommend treatment initiation at <350.  As WHO strives to lead the fight

against the global HIV/AIDS epidemic, the agency’s guidelines must also be

updated to reflect these current data.

Project: AHF’s advocacy call on the WHO and UNAIDS to immediately revise its

current guidelines to raise the recommended treatment initiation threshold from

a CD4+ T cell count of <200 cells/mm3 to <350.

 

Results: The trend towards earlier treatment initiation is based on several

documented factors that include improved survival and reduced disease

progression and cost-effectiveness. Other factors in the movement toward earlier

initiation include effectiveness and tolerance of newer antiretroviral

medications and the fact that successfully treated patients are at a lower risk

of transmitting the virus and as a result have a positive economic impact on

resource-constrained countries.

 

Lessons Learned: Proactive leadership of both WHO and UNAIDS on this issue will

have an enormous impact on the clinical practices in resource-constrained

countries reliant on the agency’s guidance to shape national health policy.

 

This abstract has been accepted at ICAAP 2009 Bali, Indonesia

 

AHF India Cares

Advocacy, Policy and Communication

e-mail: <mahesh.ganesan@...>

[Guest guest]

Dear Mahesh,

Re: /message/10306

I agree with you on the issue and the advocacy needs to be pursued.

HIV treatment guidelines in industrialised countries, such as the UK,

recommend that HIV treatment should be started when an individual’s CD4 cell

count is around 350 cells/mm3. Starting treatment at this time has been shown to

reduce the risk of developing both HIV-related and non-HIV-related illnesses.

However, in resource limited settings, HIV treatment is often started by

individuals when their immune systems are severely weakened, meaning that in

many cases they die before they have the opportunity to benefit from HIV

treatment. Treatment is not started until a patient’s CD4 cell count falls below

200 cells/mm3.

A major randomized, controlled clinical trial has shown that HIV-positive

patients in resource limited countries are more likely to survive and experience

less HIV disease progression if they start taking antiretroviral therapy when

their CD4 cell count is between 350 and 200 cells/mm3, rather than waiting until

their CD4 cell count falls to below 200 cells/mm3.

--

Dr RK Sood

drrksood@...

+91 9418064077, +91 9445157327