MELBOURNE, AUSTRALIA – Professor David Cooper kicked off the final opening plenary in Melbourne today with a review on antiretroviral therapy including a look at recommended drug regimens for first- and second-line treatment, the impact of antiretroviral therapy on transmission and the state of treatment roll out.
Cooper flagged studies looking at the effectiveness of lower doses of efavirenz, a vitally important drug for HIV globally and the prospect of long-acting antiretrovirals as future prospects for continued scale-up.
He summarized some of the reasons for early antiretroviral therapy including the biology of continuous viral replication and accompanying immune deficiency, the availability of simpler regimens with higher efficacy, the impact of antiretroviral therapy on serious opportunistic infections like tuberculosis and HIV, and the public health impact of treatment as prevention.
“Why the push back on early therapy?” Cooper asked. Compelling data from randomized controlled trials, doesn’t exist, “event” rates are low at high CD4 counts, current guidelines on treatment are based on expert opinion, not hard data, and life expectancy for patients on ART under currently guidelines is essentially normal.
Cooper updated conference delegates on the START trial which is looking at outcomes in persons who receive immediate antiretroviral therapy compared to a group who start therapy when the CD4 counts drop below 350. The study is now full enrolled.
Speculating on the impact of study results on practice and guidelines, Cooper suggested that if immediate treatment is found to be superior, guidelines will change to call for immediate treatment for all; if immediate treatment is found to be inferior, the status quo in guidelines will likely be maintained. He noted that if the approaches are found to be equivalent, prevention of transmission will be paramount in recommending antiretroviral therapy.
In looking at the current rollout of HIV treatment across the world, Cooper said that most people, especially in Africa, continue to initiate antiretroviral very late — at CD4 counts under 200 in many sub-Saharan African countries.
He called for more testing and the decentralization of testing, better linkage to care, better retention in care for persons before treatment initiation, task-shifting and financial support for transportation allowances for patients. He asked for consideration of home-delivered antiretroviral therapy and for the development of health information systems to track patients lost-to-follow-up.
Concluding his talk, he expressed concern about flat funding for the global AIDS response.
“It is hard to see how current funding can sustain an expansion according to the targets of WHO and UNAIDS,” he said “Since we do not yet have a vaccine or a cure, antiretroviral therapy is our major intervention. It would be a tragedy if we could not get enough people on treatment to reduce Incidence. We must finish the job.”