Here is an opportunity to realise our dream of an HIV/AIDS free generation

By Dr. Ben Masiira

On May 27, 2015, findings of the Strategic Timing of Anti-Retroviral Therapy (START) study were released.  The START study was funded by the National Institute of Allergy and Infectious Diseases (NIAID) and was conducted by the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT) at 215 sites in 35 countries including Uganda. In Uganda, Medical Research Council (MRC) and Joint Clinical Research Centre (JCRC) were the two sites that participated in the START study.

The study was designed to find out the most appropriate time an HIV infected individual can begin taking Anti-Retroviral Therapy (ART).

This study found that HIV-infected individuals have a considerably lower risk of developing AIDS or other serious illnesses, if they start taking ARVs when their CD4 cell count is higher, instead of waiting until the CD4 cell count drops to lower levels as recommended in the current guidelines. CD4 cell count, a key measure of an individual’s body defense system (immune system), has been used as the major criterion to start patients suffering from HIV infection on ART. Since ART was introduced in management of HIV/AIDS, several CD4 thresholds have been recommended and revised again and again by World Health Organization (WHO). The current WHO HIV treatment guidelines, which were also adopted by Uganda, recommend that HIV-infected individuals begin ART when CD4 cell counts fall to 500 cells/mm3 or less. Major reasons for setting CD4 thresholds was lack of resources to finance big scale roll out of ART especially in developing countries and lack of evidence about the benefit of ART among people with high CD4. Previous evidence to support early treatment among HIV-infected people with high CD4 cell counts was limited to data from observational studies and opinion of HIV/AIDS care experts.  I have previously conducted an observation study which showed that HIV-infected people who did not qualify to start ART because their CD4 cell counts were high were more likely to die than HIV-uninfected people.

The announcement of these results comes at the time when Uganda and the rest of the world have been struggling to eliminate HIV infection for the last three decades. By 2012, about 35.3 million people were living with HIV infection globally (UNAIDS report 2013) and ever since the beginning of this epidemic up to 40 million lives have been lost world wide. By 2013, 1.5 million Ugandans were living with HIV infection (2013 Uganda HIV and AIDS Progress report) and the number of people living with HIV/AIDS in Uganda is still on the rise.

Findings of the START study imply that every HIV-infected individual should be put on ART soon after becoming aware of their HIV status and that there is no need to do CD4 cell tests to start HIV infected people on ART. A part from reducing the chance of an HIV infected person to develop AIDS and other serious infections, early initiation of ART also reduces the risk of HIV transmission to others by over 90%. Therefore, if Uganda implements the recommendations of the START study and we strengthen our elimination of mother-to-child transmission of HIV, abstinence, being faithful, condom use and safe male circumcision, we could soon eliminate HIV infection and realize our dream of an HIV Free generation.

The writer is a MakSPH-CDC-MoH Field Epidemiology Fellow