07 July 2013
Just a month ago, medical journals were avidly debating how after 30 years there was no consensus on 'when to start' treatment for HIV. Then, the controversy surrounding when to start treatment was addressed in two debate articles published in BMC Medicine. Just three days ago, World Health Organisation recommended new guidelines on the use for anti– retroviral drugs for treating and preventing HIV infection and the big question now is whether it is 'doable' or will the debate continue to rage on?
As part of its effort to know the epidemic better, India has improved its surveillance system in recent years and increased the number of population groups covered. What was once a poorly understood disease has become a treatable condition. According to recent estimates there are 2.1 million people living with HIV in the country out of which 6.5 lakh are on anti–retroviral treatment. National AIDS Control Organisation officials admit though that another 17 lakh are registered for treatment and it will take a couple of years to actually implement the new WHO guidelines.
New WHO guidelines recommend offering ART at an early stage of the disease when the CD 4 cell count falls to 500 cells/mml or less. At the end of 2012, close to 10 million people across the world had access to ART and 34 million people were living with HIV. Now under the WHO 2013 guidelines, close to 26 million people are eligible for ART.
At 400 ART centres in India, treatment is initiated with a CD 4 cut off of 350. If the new guidelines are implemented, definitely then, more lives will be saved and new infections will be prevented. What has been recommended is the earlier initiation of treatment with simpler and safer regimens. Scientists working closely with HIV aver that it is only three decades since the virus was discovered. But the global response to the virus has already resulted into licensing of 40 anti–HIV drugs. Plus civil society and organised pressure groups of people have kept the disease under the public glare thanks to which free treatment is being provided. This kind of success boosts confidence that early treatment is feasible.
Yet concerns remain over the long–term side effects of therapy. Issues of drug resistance, drug reactions and access to second and third line treatment need to be considered before the policy of early ART treatment is adopted. NACO also needs to consider issues of procurement of drugs to avoid drug stock outs, providing access to treatment to geographically remotely located patients and strategies to eventually sustain the programme. A significant problem is whatever the CD cut off may be, patients are still reporting late to the health system with very low CD 4 counts and the challenge really is to detect them earlier at a higher CD 4 count.
Anuradha is a senior assistant editor based in Pune