New data helps prioritise groups for HIV treatment in low resourced settings

05 February 2018

Lancet study reveals for the first time who can benefit most from immediate antiretroviral treatment – enabling prioritisation in low-resourced settings. But who is left behind?

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A study published in The Lancet finds that people aged 50 or over, individuals with low CD4 to CD8 ratios, and those with high viral loads are the groups that benefit the most from immediate antiretroviral treatment (ART). The authors recommend that these groups should be prioritised and start treatment urgently. The findings aim to help policy makers and doctors in low-resource settings, where resources may be more stretched. 

The latest research is based on a post-hoc subgroup analysis of the landmark Strategic Timing of Antiretroviral Treatment (START) trial. It identifies for the first time who can benefit most from starting ART immediately by comparing absolute risk reduction of developing serious AIDS, non-AIDS conditions or death across different subgroups. Previous research had not tried to identify patients who might benefit most from early intervention. 

The original START trial, whose findings were published in 2015, found that initiating immediate ART for people living with HIV reduced the risk of serious AIDS, serious non-AIDS conditions, and death by 57% compared with deferred treatment. Largely in response to this, the World Health Organization (WHO) changed international guidelines and now recommends immediate ART for everyone diagnosed with HIV regardless of CD4 cell count. 

Despite the guidelines, poor access to ART and stigma towards people with HIV prevent many people in low- and middle-income countries from receiving treatment. Although ART has been rapidly scaled up since 2010, and global coverage reached 53% by the end of 2016, progress is still way off the UN target of 90% by 2020. 

“Provision of immediate access to ART for all people with HIV is challenging, and identification of patients who might benefit most from immediate ART would help policymakers and healthcare providers to prioritise treatment”, say the study authors, led by Professor Jean-Michel Molina. 

Since ART significantly reduces infectiousness in people living with HIV, as well as morbidity and mortality, prioritising specific groups for treatment could have significant cost savings for over-stretched health services, according to the study: “This analysis alludes to the cost-effectiveness of immediate treatment with regard to prevention of serious clinical events, but does not take into account the beneficial effect of immediate treatment on prevention of HIV transmission, which could substantially increase the overall cost-effectiveness of this strategy.”

 Sarah Hand, Avert’s CEO, stresses the need for universal access to ART to avoid the need to prioritise who is treated. She commented: “These latest findings support the continued need for immediate provision of ART to everyone with HIV. However, there is a risk that in applying this subgroup analysis, funders and policymakers may prioritise some groups for ART treatment and leave others untreated, including younger people. To end AIDS by 2030 we need to ensure that everyone with HIV has a right to receive this life-saving and life-enhancing treatment.”

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Written by Juliet Heller

Freelance writer