3. Promoting HIV Testing in Diverse Populations
Benefits Associated With Early Therapy Initiation
The findings of a number of clinical trials have shown the clear clinical and
virologic benefits of beginning treatment in patients with CD4+ cell count ≤ 350 cells/mm3.[Severe 2010, Blanc 2011] Similarly compelling evidence regarding therapy initiation in patients with higher CD4+ cell counts has not become as plentiful yet. Nevertheless, data from retrospective and cohort studies are accumulating in support of starting HAART in such patients.
Investigators evaluating findings from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) collaboration reported greater mortality among patients who did not begin HAART until CD4+ cell count had decreased to ≤ 350 cells/mm3 vs those who began therapy between 351 and 500 cells/mm3.
Findings were similar for patients who waited to start therapy until CD4+ cell count had decreased to ≤ 500 cells/mm3 vs those who began at > 500 cells/mm3.[Kitahata 2009, Kitahata 2010] When Sterne and colleagues analyzed the results of 18 cohort studies, they reported that deferring HAART until a CD4+ cell count of 251 to 350 cells/mm3 was associated with higher rates of AIDS-defining illnesses and mortality vs starting therapy at CD4+ cell count between 351 and 450 cells/mm3. These investigators concluded that a CD4+ cell count of 350 cells/mm3 should be the minimum level at which clinicians recommend initiation of HAART for their patients. [Sterne 2009]
Impact on Related Conditions
Other evidence includes Ragni and colleagues’ finding that antiretroviral therapy may slow progression to end-stage liver disease in patients who are coinfected with HBV or HCV.[Ragni 2009] In addition, investigators in the SMART Study Group have offered further support for the importance of early initiation of HAART with their finding that untreated HIV infection may be associated with increased risk of many non-AIDS–defining conditions, including cardiovascular disease, kidney disease, liver disease, and several types of malignancy. [el-Sadr 2006]
Another important reason to identify and treat patients with undiagnosed HIV infection is the risk of developing resistance to antiretroviral drugs, as shown by Uy and colleagues’ evaluation of findings from the HIV Outpatient Study (HOPS).[Uy 2009] Another important consideration is lower risk of HAART-associated adverse events in patients who initiate therapy earlier. [Lichtenstein 2008]
Community Benefits
Early initiation of HAART following early diagnosis of HIV infection can also have epidemiologic and community benefits, as well as those for individual patients. Efficacious antiretroviral therapy and behavior change have been shown to be associated with lower incidences of HIV transmission in individuals who are aware that they are HIV-positive vs those who are not aware that they are positive (estimated to be approximately 20% of the HIV-infected population). [Marks 2006] Evidence of reduced rate of heterosexual HIV transmission was reported in an analysis by Donnell and colleagues. [Donnell 2010] Considered together, the findings of studies such as these emphasize the view that early HIV diagnosis and effective HAART, combined with risk-reduction messages, can lead to reduced rates of HIV transmission.
