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Cautious approach warranted

In a radical shift in its HIV prevention strategy, the World Health Organisation is exploring the possibility of starting antiretroviral therapy (ART) immediately after a person is found to be HIV positive. In a paper published recently in the Lancet, the author, based on a mathematical model, has explained how this strategy will help bring down the occurrence of new cases by 95 per cent within ten years. The current guidelines advise starting ART treatm ent only when the CD4 count, an indicator of a person’s immune system status, dips below 250. Since it normally takes some time for the CD4 count to reach this level, and as a person is relatively symptom-free when the count is high, the chances of others getting infected — unknowingly — from the individual are greater. Hence the suggestion that the infection be diagnosed at the earliest and treatment started immediately thereafter. This, the paper contends, is a better strategy to “eliminate HIV transmission” because the chances of transmitting the infection are low when the viral load is less.

The strategy envisages an intensive screening, at least once a year, of people above 15 years of age. Since the testing is voluntary, there is the real possibility of a chunk of the target group being missed out. No programme of testing or treatment that is voluntary is likely to succeed unless the target individual is convinced he stands to gain personally by submitting himself to it. The aggressive treatment the new strategy envisages has — as noted in a comment article carried in the same issue of the journal — ‘public health benefits’ as the predominant motivating factor. Secondly, if experience with anti-tuberculosis programme is anything to go by, there is likely to be a large number of dropouts from treatment, which in turn will lead to the problem of drug resistance. In fact, the chances of drug resistance setting in are greater if ART treatment, which is for life, is started much earlier, as proposed. The objective should be to keep the incidence of drug resistance to the minimum since second-line treatment is prohibitively expensive. The WHO has to gather strong evidence to support the role of ART in preventing HIV before deciding to revise its current policy. It has also to collect data on treatment refusal, dropout rates, and the emergence of drug resistance.

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