Step by step, the recommendation to start giving antiviral medication as soon as possible to all people with HIV is gaining positions. If last year the World Health Organization and expanded the requirements for initiating treatment in Spain has been the specialist group GESIDA which, in the document of recommendations developed for this year's National AIDS Plan has go in the same direction. " Providing ART to all patients with HIV infection is recommended [ antiretroviral therapy ] to prevent disease progression, reduce transmission of the virus and limit the potential adverse effect on coexisting comorbidities," says the text.
This wording implies going beyond what was done so far, that the criteria for initiating treatment had a number of very clear cut: the concentration of CD4 (a type of lymphocytes, the immune cells that are destroyed by the virus) per milliliter of blood. If a healthy person this amount is around 1,000 cells, infected was considered that the administration of medication should always start when this number was down to 350 and almost always when he was under 500. Other factors such as the amount of virus present and the presence of comorbidities, but this indicator was the key to starting treatment.
The change may have a significant impact. In Spain it is estimated that about 150,000 people infected with HIV. The figure can never be closed, because there is a percentage, which may be around 30% of people who do not know their status. Furthermore, there is no official record of how many infected have died, either by AIDS (the disease caused by the progression of the infection) or for other reasons. What is known is that there are currently about 100,000 receiving treatment (98,011 exactly according to ministry data, 2012), so I would extend it to include up to 50,000 people. And this implies a high cost. Using a generic triple therapy, about 4,000 per year per person, or what is the same, 200 million if all received drugs. This recommendation would be carried to the extreme and if you got to identify all infected persons. If you can not be much less, depending on how many you are diagnosed. The money would have to leave the ministries, since the medication is used in hospitals and those affected is distributed free.
GESIDA president, Juan Berenguer, is blunt in his assessment of change in the document. "It's the first time in Spain the treatment to all HIV-infected patients is recommended. To date, only the DHHS (Department of Health and Human Services) of USA and the IAS (International AIDS Society / USA) made ​​this same recommendation. " " Keep the main criterion of CD4 is too reductionist. The evolution of a less toxic treatments and studies on aging of patients indicate that it is better to try soon. Not to mention its effect on the general population and the spread of the virus would be reduced, "he explains.
The evaluation report, however, is not so radical. "The strength of the recommendation depends on the circumstances," admits the text. And these respects Elena Andradas, deputy director general of Promotion and Epidemiology (and head of the National AIDS Plan once it was abolished after the arrival of Ana Mato at the Ministry of Health) to insist that there is "assessment criteria ". "We have to do an individual study, because the recommendation is from the strongest level A, one B- III, when there is such a strong scientific evidence," says Andradas.
The ministry official denied that this safeguard is to save. " All indications are that the medication reduces transmission, but that will have to review it," he insists. "Also, once you start receiving medication, this is for life, and that always has side effects." So Andradas believe the correct reading of the document is established to be a group of people to start recommending regardless of their level of CD4, and one for which there will be to make an " individualized assessment."
The document includes this aspect by stating that " initiation of ART should always be assessed individually. Before deciding to start odds CD4 + lymphocytes and CVP should be confirmed [ plasma viral load, the number of copies of HIV in the blood and in people with good medical management becomes undetectable ]. In addition, the patient must be prepared, offering options, tailoring the therapeutic approach to lifestyle, comorbidities and possible interactions and assessing the risk of poor adherence [ monitoring and treatment compliance ]. "
In the document, the recommendation is strong for people over 55 years, hepatitis B or C, malignancies, neurocognitive disorders, kidney disease, cardiovascular risk, pregnant women or people with uninfected partner by HIV (which are referred to as discordant). This would exclude those under age 55 without other diseases.
In any case, the medical society believes it's worth going to a treatment scale. Beginning because it would avoid something detected in a study last year and led by Pere Domingo, which stated that between 5% and 8% of patients with then current guidelines were candidates for medication did not, and that, in these cases 60 % were for medical decision, and 40% by choice.
The State Coordinator of HIV / AIDS (CESIDA), the largest grouping of NGOs concerned admits the impact of change on those affected. "In the case of discordant couples are clearly in favor, because their relationship much easier," says Juan RamÃ_n Barrios, member of the executive CESIDA. On the generalization of treatment, however, shows some reservations. "That is not so clear. Must see the effect on the virus premature aging and medication, for example, or the alterations that occur in renal, metabolic function and triglycerides, "says.
Only one group of victims would be out: the 5% or 10% that controls the virus without needing medication. " As an exception the patients maintaining undetectable viral load in a sustained manner without ART (elite controllers) are considered. In this case there is no data to assess the beneficial effect of ART, so you can not make a recommendation, " allowed physicians.
Tags: advise, experts, HIVinfected, treat