New US treatment guidelines

The US Department of Health and Human Services (DHHS) issued the guidelines this March and they strongly advise that anyone with a CD4 count below 350 or between 350 and 500 should start treatment. It also surprisingly advises people with a CD4 count over 500 to start. The main reasons for these revisions are:

Viral replication

The main purpose of starting antiretrovirals is to reduce the HIV replication in the body and get the viral load as low as possible – hopefully to an undetectable level. Studies have shown that even with a good CD4 count, the virus is still replicating and causing damage to the immune system. So suppressing this will hopefully strengthen the immune system.

Reduction of non-AIDS-defining illnesses

Another advantage of starting treatment early is that it may reduce the likelihood of heart, kidney, liver and brain problems and also of cancer. Although these are not problems that are directly related to HIV/AIDS, research shows that untreated HIV may contribute towards them. This is because having HIV in your system will be causing inflammation to your immune system, which will stop it from working properly.

Treatment as prevention

Studies have found that people who are on HIV treatment are less likely to pass on HIV, as their viral load is likely to be low or undetectable. So another benefit of starting treatment at a higher CD4 count will be to reduce the amount of infectious HIV within the general population.

The DHHS recommendations are based on the findings of several major studies which bear out this advice, particularly for the people with CD4 counts between 350-500. There is less evidence that it is beneficial to start HAART with a CD4 count above 500 - researchers have made that recommendation based on the benefits treatment has in reducing non-AIDS-defining illnesses and the benefits of treatment as prevention.

Of course some people may decide not to start treatment at a higher CD4 count because of the unknown long-term effects of taking HAART. The authors of the study point out that this is a drawback to starting treatment early but they feel this outweighs the benefits of drawbacks of viral replication.

As there is no reliable proof that starting treatment with a CD4 count above 500 is beneficial, the guideline s particularly recommend prioritising treatment for people with the lowest CD4 counts - pregnant women or people with kidney problems, a history of AIDS-defining illness or people who are co-infected with HIV and hepatitis B.

Read more about the new American treatment guidelines.