On February 12, just in time for Valentine's Day, the U.S. Department of Health and Human Services (DHHS) antiretroviral treatment (ART) guidelines panel issued updates to their recommendations for when people living with HIV should start ART and which drugs are best to use, among other important treatment considerations.
Though there were a number of changes, three key areas are worth mentioning. First, though the guidelines panel still recommends that ART be offered to all people with HIV regardless of the status of their immune health, measured by CD4 cell counts, and though the strength and weight of that recommendation did not change, the data cited by the panel to back up their decisions was supplemented with additional studies.
This is notable, because the Institutes of Medicine recommends that guidelines panels base their decisions on high quality data. There is exceptionally strong data that starting ART when CD4 cells drop below 350 is protective not only against major illness, but also death. Data is moderately strong for starting when CD4s drop to 500. The data on treating at higher CD4 counts has been a bit mixed, however, and experts don't expect to have a more definitive answer until a randomized control study currently underway concludes in 2015 or 2016.
- The European Union has teetered on the brink for over a year and each announcement of a "rescue" is following by another announcement threatening impending collapse. Many experts suspect that if countries such as Greece or Spain end up being forced out of the Union, our own economy will slide back into a recession, thus leaving the biggest donor nations in dire financial shape.
- Exploding economies in China and Brazil have begun to slow down, lending further weight to fears of more economic woes for us all in the near future.
- When new efficiencies and costs savings were realized in the resource-poor nations where HIV treatment has been expanded, the U.S. government chose to cut money out of global funding for AIDS rather than commit the additional money they'd originally pledged toward expand treatment to more of the millions who still go without ARV therapy. When people claim that HIV is a "manageable chronic disease," I can only laugh bitterly at their naivete when I think of the millions who still don't have access to ARVs. You can't manage your disease if you don't have the medicine.
- Experts say that Republicans--who have vowed to disable or kill the Affordable Care Act--could easily win both the Senate and the Presidency and make good on that promise. I'm astounded when I hear my compatriots claim that Obama has a good shot at winning a second term. No president, aside from Franklin Roosevelt, has ever won a second term with an economy as bad as ours is. Mitt Romney may be incredibly unlikeable, but that won't matter if middle-of-the-road independent voters in swing states who are disenchanted with Obama outnumber the young people and people of color who swept Obama and many Democratic representatives and senators to victory in 2008--and voter suppression laws have already been put on the books or expanded in many of those swing states that disproportionately target those predominantly Democratic voters. If you care about the people with HIV, and if you further recognize the need for the Affordable Care Act with all of its flaws, you absolutely must do everything you can to ensure victories for Obama and a number of vulnerable Democratic senators and representatives throughout the nation.
- Insist that our local, state and federal AIDS organizations are advocating for demonstration projects in our communities. We'll never learn how to use PrEP safely and effectively if we don't. The AIDS Vaccine Advocacy Coalition (AVAC) will be helping us keep tabs on demonstration projects and the target communities of those projects on their website (www.avac.org).
- Let's do what we can to reduce the stigma associated with participating in these kinds of trials. If we hear our peers or our community leaders denigrating HIV-negative people who struggle with safer sex or who might be considering PrEP, or claim that people can't be trusted with this technology let's call them on the carpet.
- The guidelines subtly altered their recommendation for starting treatment with CD4 cells above 500. Where the guidelines used to say that the committee was split and that it was largely up to the provider and patient, the new guidelines say that treatment should be offered to all such individuals, but that the weight of the recommendation (which is not the strongest) should be explained.
- The committee now recommends that providers explain how treating HIV can keep people from passing on HIV to their sex partners.
"In 2010...of the estimated 942,000 persons with HIV who were aware of their infection, approximately 77% were linked to care, and 51% remained in care. Among HIV-infected adults in care, 45% received prevention counseling, and 89% were prescribed ART, of whom 77% had viral suppression. Thus, an estimated 28% of all HIV-infected persons in the United States have a suppressed viral load."
- Only 51 percent of people who know their status stay in care.
- Just 28 percent of people who know their status have a suppressed viral load.
- Less than half of people with HIV received prevention counseling.
- Given that the average CD4 cell count at diagnosis in most urban settings is well under 500, it is safe to assume that a lot of people who should be on treatment by the old guidelines aren't even in care at all, and of those who are in care a lot of them are not properly treated or supported in their treatment.
- Some research indicates a huge communications disconnect exists between providers and patients. It reveals that providers often say something along the lines of "You really should be on treatment, but it's important to be ready," and that when doctors say this their patients actually hear: "Treatment right now is optional and we'll wait until you're ready."
- Random sampling indicates that a sizeable number of people who work in test centers or as case managers or as community leaders are unaware of what the guidelines say and frequently offer misinformation about both the benefits and potential side effects of treatment.
- When asked why they don't talk about sexual risk behavior more frequently, many providers say they don't have the comfort or the time to do so.