Part Three – Early Treatment for the Good of All?
What if you went to the doctor, and the doctor said, “We know that even though you have HIV, you are healthy and feel great. But, we want to put you on some medication anyway. Our research has shown that this will help prevent you from passing on the HIV, but it may also make you feel terrible and make you even sicker in the long run.”
This is the crossroads health authorities have arrived at, one where individual health priorities could become dwarfed by a public health imperative to start using HIV treatment as HIV prevention. Recent studies have demonstrated that individuals on HIV treatment are less likely to pass on HIV, primarily due to decreased levels of the virus in their bodies (see Treatment as Prevention Parts 1 and 2).
Based on a recent mathematical modeling study, the impact of this could be dramatic in a country like South Africa with a generalized HIV epidemic. The study measured the impact on HIV transmission if all people received universal voluntary HIV testing followed by immediate treatment with anti-retroviral therapy.1 The results are striking, predicting that new HIV infections would drop by 95% within 10 years.2
This seems like wonderful news, a way to end new HIV infections and to stem the tide of a devastating global pandemic. But, this study ignores one very important factor- whether the people actually need treatment! In a North American context, people newly infected with HIV can often live for 10 years without experiencing symptoms. Treatment is typically not started until a person’s immune system starts to falter or the person starts to develop opportunistic infections.
The reason for delaying treatment is to postpone serious medication side effects such as fatigue, nausea, diarrhea, facial wasting, lipoatrophy and neuropathy.3 This delay may also enable people to postpone onset of significant liver, kidney and other health problems.4 Finally, people may develop drug resistances over time so it may be better to delay treatment in order to help prolong treatment efficacy given the limited number of treatment options available.
There are new studies which challenge the exact CD4 count at which people should start treatment.5 However, there is still a general consensus that treatment should be started when an individual’s health status warrants it. Ultimately, individuals have a fundamental right to individual treatment determination, and any public health policy must respect the importance of this.
Before implementing broad based treatment programs for the sake of prevention, it is also important to recognize that regular risk reduction strategies and safer sex practices are still effective ways of preventing HIV transmission. For those who do not engage in high risk activities, placing them on early treatment may simply force them to compromise their good health in order to prevent transmission of a virus they weren’t going to transmit anyway.
Clearly, HIV treatment has an important role to play in improving the health of individuals and contributing to a reduced risk of HIV transmission. Likewise, wider HIV testing in our community would help diagnose people living with HIV earlier and reduce their risk of unknowingly passing on the virus. However, any major shifts in treatment or testing policy must carefully weigh the rights of individuals and the possible long term health impacts on them against the possible benefits of a new and controversial approach to treatment as prevention in our communities.
1 Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. 2008. Granich, Reuben M, Gilks, Charles F Gilks, Dye, Christopher, DeCock, Kevin M, Williamns, Brian G. The Lancet. Retrieved January 2009 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61697-9/fulltext
2 Math model: HIV can be eliminated in a decade, 2008. Associated Press. Retrieved January 2009 http://www.msnbc.msn.com/id/27911541/
3 HIV Medications: When to Start and What to Take, 2006.The Body. Retrieved January 2009 http://www.thebody.com/content/art12718.html and Side Effects, Opportunistic Infections and Coinfections Prevention and Treatment, The Body. Retrieved January 2009 http://www.thebody.com/index/treat/oipage.html
4 A Practical Guide to HIV Drug Side Effects, 2006. Canadian AIDS Treatment Information Exchange. Retrieved January 2009 http://www.thebody.com/content/art46570.html
5 Growing Evidence Supports Early Treatment, 2008. Dalton, Paul. Project Inform. Retrieved January 2009 http://www.thebody.com/content/treat/art47351.html
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