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Do new HIV therapy guidelines go far enough?

By Brad Balukjian

10:40 AM EDT, July 6, 2013

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The World Health Organization’s new recommendation that people with HIV begin treatment with antiretroviral drugs sooner rather than later doesn’t go far enough, according to a prominent immunologist at the University of California, San Francsico Medical Center.

On Sunday, the WHO changed its position on how long people should wait before they start taking ART, a trio of virus-fighting drugs known as the HIV cocktail. In 2010, the health experts said treatment should begin after the number of CD4 immune system cells dropped below 350 per cubic millimeter of blood. Now they say the threshold should be 500 cells per cubic mm of blood. The health agency estimated the change would increase the number of people eligible for ART from 9.7 million to 26 million and avert 3 million deaths by 2025, according to a statement.

But even that is not enough, said Dr. Arthur Ammann, who has been fighting the HIV epidemic since 1981.

Ammann said the new recommendations are dangerously limited. Instead of measuring a patient’s CD4 cell count, doctors should just begin treatment immediately following an HIV-positive diagnosis.

“You’re keeping people from going on treatment that are deserving of treatment,” he said. “They deserve to have antiretoviral drugs if they’re available.”

Anmmann’s views are in line with the recommendations of the U.S. Department of Health and Human Services.

But Dr. Monica Alonso, an HIV advisor for WHO and the Pan American Health Organization, replied that there is insufficient data to support Ammann’s recommendation.

“All WHO recommendations are based on evidence,” Alonso said in an email. “Currently there is no evidence to support a ‘test and treat’ approach to all patients.” She  added that WHO now recommends treatment for infected subpopulations, such as pregnant women, irrespective of CD counts.

Ammann has been treating people with HIV for more than 30 years. He co-diagnosed the first child with AIDS in San Francisco, an event he said “changed my career.” Around 2000, he decided to shift gears from the lab bench to the villages where HIV does the worst damage.

“Clinical research gave us the results we needed, but treatment wasn’t being implemented in the poorest regions of the world,” he said.

Ammann formed a non-profit organization called Global Strategies, whose mission is to provide ART to those countries most in need, such as Liberia, Zimbabwe, and the eastern Democratic Republic of the Congo.

These countries are also too impoverished to afford the CD4 cell-counting machines that are needed to make the diagnoses that fit the WHO’s recommendations. Even if they did have the machines, they couldn’t afford to provide patients with ART, he said.

Ammann suggests that the WHO’s guidelines are based on economics rather than medicine.

“They say these countries can’t afford to treat all of their patients, but that’s not really true,” he said. “Antiretroviral treatment used to cost $10,000 to 12,000 a year per patient, but now that same treatment costs $100.”

The WHO declined to respond to that charge, but emphasized that the testing guidelines were based on extensive input from outside experts around the world.

But Ammann said it’s still not enough.

“There’s never been an infectious disease or cancer in modern medical history where treatment has been withheld until the patient gets sicker,” he said. “You’re basically looking at the patient and saying, ‘I know you’re HIV-infected. I have medicine to treat you. But I’m going to let you progress to worsening of the disease until I give you the drug.’”

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brad.balukjian@latimes.com

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