Start HIV study changes treatment guidelines across the planet
All HIV-positive people eligible to receive antiretroviral treatment should receive it regardless of CD4 cell count, according to the new British HIV Association (BHIVA) treatment project, the study START HIV, That changes HIV guidelines.
The new draft guidelines, published for consultation this week, say that someone who lives with HIV, and who understands the seriousness of commitment to treatment, and is ready, psychically speaking, to start what changes him to HIV-positive treatment guidelines, the study, you should receive treatment. The change - from a recommendation to start treatment before the CD4 cell count falls below 350 cells per milliliter of blood for a treatment for all seropositive - follows the results of the START HIV study, an international study intensely expected when to start treatment.
The START study showed that starting treatment with a CD4 count above 500 cells per cubic milliliter of blood has reduced the risk of death or severe illness in 53% compared with waiting to start treatment until the CD4 count fall to 350 cells per cubic milliliter of blood. Although the absolute risk of death or serious illness is small - 3,7% persons in the differential treatment arm became seriously ill or died, compared to 1.8% in the immediate treatment group, after more than three years of follow-up - the Committee of BHIVA guidelines concluded that the evidence now supports the provision of treatment to all people willing to receive it.
Two other recent studies, the Early Study and HPTN 052, also influenced the decision to offer treatment to all as the results of the start HIV study say.
Temprano, a study in West Africa showed that starting treatment at a cell count CD4 above 500 reduced the risk of severe disease and death in 44% compared to the beginning of treatment in low CD4 count.
The study HPTN 052 held in sub-Saharan Africa, India, Brazil, Thailand and the United States, showed that early treatment - starting with a CD4 cell count between 350 and 550 - reduced the risk of clinical disease 40%, but It did not significantly reduce the risk of death compared to starting treatment at a count of CD4 cells below 250 cells per cubic milliliter of blood.
HPTN 052 also demonstrated that immediate treatment reduced the risk of sexual transmission of HIV in 96% [Soropositivo.org Editor's Note: Why, then, Lord, criminalize people living with HIV simply by not revealing their HIV status before beginning a sexual relationship?]. based on the previous recommendation of BHIVA, that someone living with HIV should have treatment started immediately because they believed that this could reduce the risk of HIV transmission - and that all people living with HIV should be informed by their doctors of the evidence linking antiretroviral treatment to a reduction in the risk of transmission.
Data presented by the UK Health Surveillance earlier this year show that this recommendation coincided with a substantial increase in the proportion of people starting treatment in the CD4 count above 350 by the end of 2013 - but only 27 people started the treatment with a CD4 cell count above 500 that year.
The updated guidelines continue to emphasize this evidence and recommend that physicians should continue to discuss the potential for reducing transmission with all people living with HIV. Seropositive persons should be evaluated for immediate initiation of treatment after diagnosis, but initiation of treatment should only be considered AIDS defining illness, bacterial infections severe or with a cell count below CD4 200 cells per cubic milliliter of blood. People in any of these categories should start treatment within two weeks at most, the guidelines recommend.
Recently infected persons - diagnosed with someone Primary HIV infection within 12 weeks after a previous negative test - should be encouraged to initiate treatment immediately in order to improve immune recovery, limit the size of the viral reservoir and limit the potential transmission of the disease at a time of very high viral load. Someone diagnosed with primary HIV infection who has a CD4 cell count below 350 cells per cubic milliliter of blood, one AIDS defining illness ou neurological symptoms should also be encouraged to start treatment so they can.
Other people diagnosed soon after infection should be invited to consider the initiation of treatment the same way as any other person diagnosed with HIV - when they feel prepared for it.
The guidelines also make one more change by recommending treatment based on efavirenz as the standard regimen for first-line treatment.
Efavirenz was at the heart of anti-retroviral first-line treatment in the UK for almost 15 years and has been the preferred choice of first line, since 2008, but recent experimental results have shown that some other agents are superior in some patient populations.
Trials have also reinforced doubts about the long-term tolerability of efavirenz.
Efavirenz has been downgraded to an alternate choice the first time. Instead, the guidelines now recommend that (in the UK) the first-line regimen should be based on:
- an integrase inhibitor - dolutegravir (Tivicay also available in pill "Triumeq" (a combination with abacavir and lamivudine), raltegravir (Isentress) or elvitegravircobicistat (Vitekta and Tybost also available in tablet Stribild combination with tenofovir and emtricitabine);
- a potentiation protease inhibitor (atazanavirritonavir or darunavirritonavir)
- the new non-nucleoside reverse transcriptase inhibitor, Rilpivirine, (Edurant, also available on the combination tablet Eviplera with tenofovir and emtricitabine).
Physicians have been asked to request information about sleep quality and mood at each clinic visit of those taking Efavirenz (Editor's Note: Natasha Roxy, our collaborator, has reported "realistic dreams and an unwillingness to work under the effect of this drug - Efavirenz, which has been used, according to anonymous reports, as" recreational drug "in order to identify people who may benefit from switching to a drug better tolerated.
The preferred central axis for first-line treatment remains tenofovir and emtricitabine with abacavir and lamivudine as an alternative where people have no viral load above 100.000 copies per cubic milliliter of blood. Abacavir and lamivudine can be used in any viral load when combined with dolutegravir in the Triumeq combination fixed dose pill because of high potency of dolutegravir.
Abacavir is not suitable for use by people with a genetic profile that makes them hypersensitive to the drug, and everyone should be tested for the genetic marker HLA-B5701 to filter out people who are likely to be hypersensitive before starting treatment with the drug.
Abacavir should not be used in people at high risk of cardiovascular disease, and tenofovir should not be used in people with chronic kidney disease stage 3-5.
Published: June 24 2015
Translated from original New British guidelines recommend treatment for everyone with HIV by Claudio Souza with Review of Mara Macedo in 28 July 2015
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