This article previously appeared in HIV Update, a publication of Aidsmap.com, here.
Anyone living with HIV who understands the commitment of treatment and is ready to start should receive treatment, according to the draft guidelines. The decision to start treatment rests with the person living with HIV.
The change from a recommendation to start treatment before the CD4 cell count falls below 350 cells/mm3 to treatment for all follows the results of the START trial, a keenly awaited international study described in the last edition of HIV Update.
The START study showed that starting treatment at a CD4 cell count above 500 cells/mm3 reduced the risk of death or serious illness by 53% compared with waiting to start treatment until the CD4 count fell to 350 cells/mm3. The absolute risk of death or serious illness was small – 3.7% of people in the deferred treatment arm became seriously ill or died, compared to 1.8% in the immediate treatment group over three years of follow-up. Nonetheless, the BHIVA guidelines committee concluded that the evidence now supports offering treatment to everyone prepared to take it.
There are a few situations in which treatment is needed more urgently, with the guidelines recommending that it be started within two weeks. This is the case for people with a CD4 cell count below 200 cells/mm3, an AIDS-defining infection or a serious bacterial infection.
The guidelines also make a shift away from recommending efavirenz in first-line treatment. Doctors should ask people who are already taking efavirenz about sleep and mood, in order to identify people who might benefit from switching to an easier-to-take drug.
The guidelines now recommend that first-line treatment should be based on either an integrase inhibitor, a boosted protease inhibitor, or the new non-nucleoside reverse transcriptase inhibitor rilpivirine.
When drugs are equivalent in terms of efficacy and safety, cost should be a consideration in prescribing. But prescribing on the basis of cost should not be permitted to affect patient outcomes or quality of care.
The draft guidelines are open for consultation and feedback, until 17 July. You can submit comments here.