Since the arrival of the first anti-HIV drug in the late 1980s, the question of when to begin treatment in the course of HIV disease has ignited debate. Over the years, recommendations about the ideal treatment starting point have moved back and forth between early and late initiation. In the past decade, however, the evidence about when it’s best to start treatment began to evolve only in one direction—early in the course of HIV disease.
The pivotal factor that cemented the importance of early initiation of treatment (commonly called ART) came with the release of results from a large clinical trial called START. This data was presented at the International AIDS Society’s conference in July 2015 in Vancouver. As a consequence of START’s results, leading international treatment guidelines from the United States, the United Kingdom and the World Health Organization now recommend that all HIV-positive people be offered treatment, regardless of their CD4+ count. The results from START and other studies also suggest that immunological injury arising from HIV infection occurs early, which underscores the need to initiate ART as soon as possible.
Recently, the Association of Medical Microbiology and Infectious Disease Canada (AMMI) made this recommendation in a position statement:
“In Canada antiretroviral therapy (ART) should be initiated in all adult persons living with HIV-1 infection as soon as a diagnosis of HIV infection is confirmed and regardless of CD4+ count.”
The AMMI position statement notes that a person’s ability to take his/her medicines every day, exactly as directed, is critical to the success of ART.
Changing the course of an epidemic
The early initiation of ART has benefits for the person taking it, including preserving his/her immune system and reducing the risk of developing serious complications. ART also lowers the amount of HIV in a person’s blood to very low levels (commonly called undetectable). By taking ART every day and staying in care, receiving regular monitoring and blood tests, ART users can maintain undetectable blood levels of HIV, which significantly reduces the risk of sexual transmission of the virus. This latter effect carries tremendous potential that is recognized in the AMMI position statement: “Early and long-term [use of] ART may ultimately change the course of the HIV epidemic.”
Don’t forget sexually transmitted infections
Although studies have found that ART can significantly reduce the risk of HIV transmission, AMMI notes that ART “does not prevent” the spread of other sexually transmitted infections (STIs). This underscores the importance of condom use to reduce the risk of getting STIs.
Mind the Canadian gap
The Public Health Agency of Canada (PHAC) estimates that there are about 76,000 HIV-positive people living in Canada. Researchers are uncertain as to how many of these HIV-positive people are on treatment. However, according to the AMMI statement, estimates from the pharmaceutical industry suggest that between 30,000 and 35,000 HIV-positive Canadians are taking ART. If the industry estimates are correct, there is clearly a substantial gap in care and treatment. However, Canada’s provinces and territories are taking steps to increase the number of people receiving voluntary HIV testing and counselling and a swift referral to care in cases of a positive test result. Once in care, such patients can receive the offer of treatment.
For ART to be a success for both the individual and society, the AMMI statement notes that supports will be necessary to promote daily medication-taking and ensure that patients stay engaged in their care. The statement gives specific examples of such supports:
- patient health navigation (supports to help patients navigate the health system)
- community and peer outreach
- provision of culturally appropriate print media
- verbal messages promoting healthcare utilization and retention in care from clinic staff
- youth-focussed case management
- support systems and linkage for broader health care needs
One factor that affects the gap in care and treatment is that approximately 21% of people with HIV in Canada do not know their infection status, according to research by PHAC.
Taking all of these estimates into account, the AMMI position statement notes that “it will be necessary to continue to build more capacity in health care resources for [HIV-positive people] to realize a meaningful impact on patient-specific and public health outcomes.”
The AMMI statement is a very important step forward to help guide Canadian efforts to reduce the spread of HIV. In closing its statement, AMMI declares the following:
“Guidelines recommending early initiation of ART will only be effective when accompanied by comprehensive prevention, treatment and care programs and policies that address stigma and discrimination and ensure long-term adherence to therapy.”
Detailed results from the START study – TreatmentUpdate 210
Changing the Narrative: Why HIV prevention work in Canada needs to embrace HIV treatment – Prevention in Focus
Progress on Ontario’s HIV care cascade – CATIE News
The Epidemiology of HIV in Canada – CATIE fact sheet
Health Navigation – Programming Connection
Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents – U.S. Department of Health and Human Services
—Sean R. Hosein
Becker M, Cox J, Evans GA, Haider S, Shafran SD. AMMI Canada position statement: The use of early antiretroviral therapy in HIV-infected persons. AMMI Canada position statement. April 2016. Available at: https://www.ammi.ca/download/Guidelines/ALL-Final-Web-posted-AMMI-Position-Statement-Early-ART-April-18-2016new.pdf