HIV Patients Should Start Drug Treatment Right Away, New Guidelines Say

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Thousands of scientists, doctors, policymakers and people living with HIV are meeting this week for the annual International AIDS Conference in Washington, D.C., the first time the conference is being held on U.S. soil in 22 years.

The goal is to try to turn some crucial advances in HIV research into practical measures to save lives. In recent years, studies have found, for example, that using HIV treatment drugs can prevent infection in healthy people; that circumcising men can protect them from HIV; and that treating patients early, before they become sick, reduces the risk that they’ll infect others with the virus.

‘‘Future generations are counting on our courage to think big, be bold and seize the opportunity before us,’’ Dr. Diane Havlir of the University of California, San Francisco, a co-chair of the International AIDS Conference, told the AP.

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To coincide with the conference, this week’s issue of the Journal of the American Medical Association (JAMA) is devoted to new research on HIV. One study, focusing on the benefits of early treatment, issues new recommendations for adults with HIV, advising that all patients be treated immediately potentially life-saving antiretroviral medications, or ARVs.

The new guideline comes from the International Antiviral Society-USA panel, and revises current recommendations, which advise that drug treatment should begin when levels of patients’ immune cells, known as the CD4 count, drop below 350 cells per mm3 of blood. The new guidelines initiate treatment immediately, regardless of a patient’s CD4 count.

The panel says that it revised its advice for ARV treatment based on studies conducted over the past two years, which show that patients at all stages of infection may benefit from drug treatment. In particular, trials in which HIV-positive patients began ARVs soon after infection showed that they could lower their risk of tuberculosis, bacterial infections, other AIDS-related complications and even death from the disease by 41%, compared with those who waited to start therapy later, when their CD4 counts dropped to 350. In another study, those who began drug treatment at CD4 counts of 350 had a 38% increased risk of developing full blown AIDS and dying prematurely of the disease than those who didn’t wait as long to start ARVs.

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The question of when to initiate ARV has always been a tricky one for AIDS clinicians; because the drugs have serious side effects, doctors must balance their potential life-saving benefit against these adverse events, including cancer and lipid imbalances. But with advancements in drug development, newer therapies that are easier to take have made it possible to start patients earlier, and when it comes to confronting HIV, experts say, the sooner the better.

The guidelines include recommendations for which drug combination newly infected patients should receive. The combinations include a cocktail of four medications that all hit HIV at different points in its life cycle: two nucleoside reverse transcriptase inhibitors, a non nucleoside reverse transcriptase inhibitor, along with either a ritonavir-based protease inhibitor or an integrase inhibitor.

Starting drug treatment for all HIV-positive patients may also have another benefit — recent trials have hinted that hitting the virus hard with anti-HIV medications soon after a person is infected may hamper HIV’s ability to jump from that patient to a new host during sexual contact. If that’s the case, then the new guidelines may also help to reduce transmission of the disease. “There is no CD4 cell count threshold at which starting therapy is contraindicated,” the authors write.

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In the other papers appearing in the JAMA theme issue, scientists report:

Differences in foreign-born and U.S.-born HIV patients in the U.S.
Among the 191,697 people diagnosed with HIV and living in the U.S. between 2007 to 2010, 16% were born outside of the U.S. The four states reporting the highest numbers of people born outside the U.S. and diagnosed with HIV (California, Florida, New York and Texas) were also the top four states with HIV cases overall.

Nearly 40% of foreign-born, HIV-positive patients were infected via heterosexual contact, compared with 27% of U.S.-born patients. For men born either in the U.S. or in another country, the majority of HIV diagnoses were in men who have sex with other men.

By race or ethnicity, the proportion of HIV patients born outside the U.S. varied: among white patients, 3.3% were born outside the U.S.; of black patients, 10% were born outside the U.S.; of Hispanics, 42.2% were foreign-born; and among Asians, 64.3% were not born in the U.S.

Of the 25,255 people diagnosed with HIV who specified a country or region of birth outside the U.S., the most common region of birth origin was Central America (including Mexico, 41%), followed by the Caribbean (21.5%), Africa (14.5%), Asia (7.9%), and South America (7.6%).

Although 95% of patients with HIV live outside the U.S., public health experts say it’s important to understand the socioeconomic characteristics of those who are foreign-born and affected by HIV and living in the U.S., to better target prevention and treatment programs that are more effective and culturally meaningful.

Hope for an AIDS-free generation
Pointing to the continued evolution in ARVS, as well as the latest understanding that the drugs can help protect healthy, uninfected people from HIV infection, authors Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), and Gregory Folkers, also of NIAID, provide hope that eventually HIV may be a scourge of the past.

ARVs have saved an estimated 700,000 lives in 2010 alone, the authors write, but additional efforts to prevent new infection can help push that number higher. Among the strategies, say Fauci and Folkers: use ARVs to prevent infection (the U.S. Food and Drug Administration approved this month the first anti-HIV drug for prophylactic use in uninfected, high-risk people); establish stronger programs to prevent transmission of HIV from pregnant women and mothers to their children; encourage male circumcision to reduce HIV transmission during sexual contact in developing nations. Combining these strategies will be essential to developing an action plan against HIV, the authors say.

“With collective and resolute action now and a steadfast commitment for years to come, an AIDS-free generation is indeed within reach,” they write. “Achieving this goal, however, will require implementing a multifaceted global effort to expand testing, treatment and prevention programs, as well as meet the scientific challenges of developing an HIV vaccine and possibly a cure.”

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Alice Park is a writer at TIME. Find her on Twitter at @aliceparkny. You can also continue the discussion on TIME’s Facebook page and on Twitter at @TIME.