KUALA LUMPAR, Malaysia -- People infected with HIV should be put on antiretroviral therapy even sooner than they are now, the World Health Organization said today as it released new treatment guidelines.
While the new guidelines, issued at an international AIDS conference in Malaysia, were an aggressive step forward, they also represent a compromise between how much the world could do to suppress the epidemic if money were no object and how much donor countries are willing to pay for.
The new guidelines recommend that drugs be initiated as soon as a patient's CD4 count falls below 500 cells per cubic millimeter of blood. CD4s are the white blood cells that the virus first attacks. The count is an index for how much of the immune system has been destroyed; 500 is the bottom of the normal range while a patient below 200 is at high risk of fatal infections. The previous cutoff point, recommended in 2010, was a count of 350; a decade ago, when donors first began buying drugs, it was 200.
For some subgroups, the new guidelines recommend starting treatment immediately upon a positive HIV test, regardless of CD4 count. Those include people with active tuberculosis or hepatitis B liver disease, those whose regular sex partners are not infected, women who are pregnant or breast-feeding, and children under 5.
Many scientists now recommend that all patients start treatment immediately regardless of CD4 levels. The evidence is overwhelming that they are far less likely to infect anyone else if they do so. They also may live longer, healthier lives because their immune systems are not allowed to sink before being revived. In rare cases when the infection is caught very early, some may even be able to safely stop treatment after a year or two.
WHO guidelines, however, are used mostly by the health ministries of poor countries that depend on donors. Not nearly enough money is contributed each year to treat everyone infected, so poor countries perform triage, telling about half of their infected citizens to wait until they get sicker.
The new guidelines mean that about 26 million people in poor and middle-income countries will be eligible for the drugs, up from 17 million under the previous guidelines. Almost 10 million people are on the drugs now. Globally, more than 34 million people are infected.
Two trends are helping increase the number of people getting treatment. The prices of drugs and diagnostic tests keep dropping, and middle-income countries are relying less on donors. South Africa, for example, has increased its AIDS budget by 500 percent in recent years.
The new guidelines also call for universal use of the simplest, most effective treatment with the least side effects: a once-daily pill containing three drugs -- tenofovir, efavirenz and either lamivudine or emtricitabine.