Things that caught my eye at #IAS2015: Updated treatment guidelines and 90-90-90 targets possible

Friday, July 24, 2015

There were quite a few studies and announcements that made headlines at this year's IAS conference, which wrapped up in Vancouver earlier this week (NAM aidsmap provided some great coverage of the conference), but two in particular caught my eye. The first, which has actually been making the rounds for several months now, is that the WHO is updating its guidelines for HIV treatment with antiretroviral medication. It is now recommended that individuals diagnosed with HIV begin treatment as soon as possible, regardless of CD4 cell count (previous guidance advised waiting until a person had a count of below 350 cells/mm3):
The new recommendation follows results from two large randomised trials, TEMPRANO and START, both released in 2015, which both showed that starting treatment at a CD4 cell count above 500 cells/mm3 resulted in less serious illness and AIDS-related deaths than if treatment was deferred.

The new guidelines, based on systematic review of trials and observational cohort data presented since the publication of consolidated WHO antiretroviral treatment guidelines in 2013, will recommend:
  • Treatment for all adults and adolescents regardless of CD4 count, prioritising those with CD4 counts below 350 cells/mm3 and those with AIDS-defining illnesses.
  • Treatment for all children.
  • Treatment for all pregnant women, leading to lifelong treatment (Option B+).
  • Pre-exposure prophylaxis should be offered as an additional prevention choice for people at substantial risk of HIV infection.
The new guidelines will lend further weight to the UNAIDS 90-90-90 target, which aims to diagnose 90% of people with HIV, treat 90% of people diagnosed with HIV and achieve undetectable viral load in 90% of people on treatment by 2020.
Speaking of the 90-90-90 target, preliminary data from several large-scale 'test and treat' studies in African countries are showing that the WHO's targets are achievable:
In Uganda and Kenya, SEARCH is a study randomising 32 communities to either an intervention of expanded testing and treatment, or usual services.
Diane Havlir told the meeting that so far, 90% of adult stable residents have accepted the offer of testing, 93% of those diagnosed have been retained in care for at least six months, and 92% of those in care have a viral load below 400 copies/ml.

PopART is one of the other large population studies, randomising 21 communities with a total population of 1.2 million people, to three different arms. Richard Hayes of the London School of Hygiene and Tropical Medicine said that interventions include annual home-based HIV testing, a range of health promotion activities and an offer of immediate antiretroviral therapy.

Based only on the first annual round of implementation, the intervention appears to be close to reaching the first 90% target, with an estimated 87% of women and 79% of men living with HIV aware of their HIV status. (Without the intervention, figures would be 56% and 53%).
On top of that, apparently Botswana and Rwanda have better HIV treatment coverage than the US (which sadly does not surprise me):
The meeting heard that two African nations, Botswana and Rwanda, appear to have better treatment cascades than the United States. These are not the results of research studies as described above, but reflect everyday services after several years of political commitment, investment in health and strong governance. Moreover, both are small countries (with populations of two and ten million respectively) which have taken advantage of unique economic and historical circumstances to reform their health services.

Both are close to reaching the UNAIDS 90-90-90 targets. However because the United States health system has considerable difficulties with linkage to and retention in care for poorer people, it lags behind.
There are, of course, ongoing issues with the studies (discussed in more detail in the article), but the results are nonetheless encouraging.

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