A Milestone In The Campaign To Reduce The Number Of Deaths From AIDS

The world's annual death toll from AIDS has been falling in recent years — 1.5 million in 2013, a 35 percent drop from the peak of 2.4 million in 2005.

Now the number of deaths could soon drop even more.

The World Health Organization issued new guidelines Wednesday that recommend greatly increasing the number of people who take antiretroviral medications for the treatment and prevention of HIV infection.

The document says that all HIV-positive people should immediately start antiretroviral treatment, which "removes all limitations on eligibility for antiretroviral therapy (ART) among people living with HIV."

Dr. Gottfried Hirnschall, director of WHO's HIV division in Geneva, said that the guidelines mean "there shouldn't be any eligibility barrier anymore." That's a potential boon for patients in low- and middle-income countries, who typically are not offered this therapy. But it does mean that money must be raised to cover the costs of ART.

Before this announcement, WHO's recommendation was to start treatment after an HIV-positive person's CD4 count dropped below 500 cells per cubic millimeter of blood. The CD4 count helps measure the strength of the immune system; a healthy person's range is usually between 500 and 1,200. When an HIV-positive person's CD4 count drops below 200, their body is less likely to fight off infection, and they are are diagnosed with AIDS.

WHO also called for far greater use of pre-exposure prophylaxis, or PrEP. PrEP is a program that involves taking a once-daily HIV pill called Truvada to prevent HIV infection. WHO says clinical trials confirmed that PrEP works "to prevent people from acquiring HIV in a wide variety of settings and populations." It's a step up from guidelines issued last year that endorsed the idea that PrEP could be useful in combatting the spread of HIV.

The recommendations were released several months ahead of the original schedule because they could "significantly reduce the number of people acquiring HIV infection and dying from HIV-related causes," according to the document.

In an interview with NPR, Dr. Anthony Fauci, director of the NIAID, said a slew of recent studies and research "have shown the overwhelming benefit of starting ARVs as early as you possibly can."

Some of the earliest HIV medications had serious side effects, Fauci said. These could include a fat redistribution called lipodystrophy that can cause sunken cheeks and a hump on the back, extreme nausea and, sometimes, psychological and neurological side effects. Previously, doctors would look at the complex regimens of drugs and ask "does that outweigh the benefit of giving the drug and suppressing the virus?"

But, today, many widely-used HIV medications have few side effects and are one pill, once a day. They can quickly push an HIV-positive person's viral load down to undetectable levels—so low that a viral load test can't find signs of the virus. And studies confirm that if an HIV-positive person stays undetectable, their chance of transmitting the virus to someone else is close to zero.

Fauci said an expansion of the use of ARVs would mean "[fewer] deaths from HIV," as well as "less illness from HIV and less infection from people who are infected."

The recommendation that anyone at "substantial risk" of contracting the HIV infection begin taking PrEP means that governments around the world may speed their approval of this new therapy. The vast majority of PrEP patients are in the United States, and the still-controversial treatment is pending approval in other countries.

In an email interview, Damon Jacobs, a psychotherapist and PrEP advocate, said "the CDC and WHO guidelines in 2014 profoundly changed the landscape of conversation, awareness, interest and implementation of PrEP."

Jacobs, who runs the Facebook group PrEP Facts, said that Wednesday's expanded guidelines "point out the need for PrEP in curtailing new infections, and the importance that officials work to make this regimen accessible and affordable."

Dr. Gottfried Hirnschall of WHO said if the guidelines are adopted around the world, the number of HIV-positive people on ART would jump from 28 million to 37 million — that's the estimated total number of people with the virus.

Hirnschall says the new guidelines are part of efforts to meet UNAIDS' newest global health goal: 90-90-90: 90 percent of HIV-positive people know their status, 90 percent of HIV-positive people are on ART, and 90 percent of people on ART have undetectable viral loads. (Hirnschall noted that the global health community met its last goal of getting 15 million people on ART by 2015.)

"We are now looking toward 2030, and one of the subgoals of the SDGs [sustainable development goals] is to end HIV as a public health threat," Hirnschall said.

But Hirnschall was more circumspect when he predicted the immediate impact of Wednesday's new guidelines. "Does this mean that Monday morning all these people are at the doorstep of the clinic in low- and middle-income settings?" he asked. "No, because many do not know they are HIV-positive."

He says the simplification of treatment in many middle- and low-income countries — and the fact that some of these countries are footing the bill for a growing share of treatment instead of relying on Western aid — has helped cut costs. In 2014, the global response to the HIV/AIDS epidemic was $21.7 billion. Hirnschall said UNAIDS estimates that it would require scaling up to about $31.7 billion annually by 2020 to meet the 90-90-90 goals.

Whether that extra funding will be found, he said, may depend on the generosity of donor countries during the next appeal by the Global Fund, scheduled for later this year.