HIV update - 10th June 2015

Important news on when to start HIV treatment

The headline findings of a major study of the best time to start HIV treatment were announced two weeks ago. These are the most significant research findings on HIV treatment to come out for some time.

The START study has shown that by beginning HIV treatment early – when their CD4 cell counts are still high – people living with HIV can significantly reduce their risk of developing AIDS, other serious illnesses unrelated to AIDS, or dying. 

Some HIV doctors (especially those in the USA) have long believed that early HIV treatment prevents future health problems. But many other doctors have, until now, argued that we haven’t had definitive proof of this. Research on this has been contradictory and not used the most rigorous research methods. Treatment guidelines in the UK and many other countries have therefore recommended that most people begin HIV treatment when their CD4 cell count drops to around 350 cells/mm³. But this advice will now change.

Announcing the results, Professor Jens Lundgren of the University of Copenhagen said, “We now have strong evidence that early treatment is beneficial to the HIV-positive person. These results support treating everyone irrespective of CD4+ cell count.”

This was a large, well-designed study. It used a randomised design in order to provide the most reliable form of scientific evidence. Close to 5000 HIV-positive people living in 35 countries in Europe, Latin America, Africa, the USA, Asia and Australia took part.

People taking part had never taken HIV treatment before and HIV had not yet substantially damaged their immune system – all had a CD4 cell count above 500 cells/mm³ and some had a much higher CD4 count.

In order to find out when is the best time to start HIV treatment, half the participants were asked to wait until their CD4 count had fallen below 350 cells/mm³. The other half started treatment straightaway.

Rates of AIDS-related illnesses, other serious illnesses, and deaths were compared. These didn’t happen to many people, but they happened to far fewer people who started treatment early.

In people who delayed treatment, around 12 in every 1000 people had AIDS, a serious illness or death each year. In people who took treatment straightaway, this happened to 6 in every 1000 people each year. This amounts to a 53% lower risk of these events occurring.

Although the researchers had thought that early treatment might have the greatest impact on rates of serious non-AIDS illnesses (like heart disease and kidney disease), in fact it made the most difference to AIDS-related illnesses (such as tuberculosis, Kaposi’s sarcoma and other cancers). This was a surprise.

We can now be confident that early HIV treatment improves the health of the person living with HIV. We already knew that it helps reduce the risk of passing HIV on.

The results are likely to mean that medical practice will change, so that treatment guidelines based on CD4 cell counts are dropped. People will probably be encouraged to start HIV treatment as soon after their diagnosis as they feel ready.

More detailed findings will probably be announced at a conference in July.

Hepatitis C treatment as prevention

Regular readers of HIV update will be familiar with the idea of treatment as prevention in HIV – effective HIV treatment reduces viral load and the risk of passing HIV on. The end result should be fewer people living with HIV.

Researchers are applying the same idea to hepatitis C, although in this case effective treatment cures the person of hepatitis C. It then becomes impossible to pass the virus on.

At the moment, around 8% of gay men living with HIV in the UK also have hepatitis C. If none had their hepatitis C treated, double this number would have hepatitis C in ten years’ time.

But if 80% of men were treated within a year of acquiring hepatitis C, and if 20% of men who’ve had hepatitis C for longer went on treatment, researchers estimate that fewer than 3% of gay men living with HIV would have hepatitis C by 2025.

For information about preventing hepatitis C transmission during sex between men, see our illustrated leaflet ‘How hepatitis C is passed on during sex’.