Vancouver, BC [September, 2015] A new study finds patients who start HIV combination antiretroviral treatment at high CD4 levels – when the immune system is still healthy – have higher likelihood of long-term adherence and better clinical outcomes. Published in the journal AIDS, the new research confirms, at the population level, the results of recent randomized clinical trials supporting immediate initiation of HIV treatment.
“Our study counters concerns among clinicians that individuals living with HIV will not feel compelled to stay on treatment because they are asymptomatic or are feeling fine,” said lead author Dr. Viviane Dias Lima, Research Scientist and Senior Statistician at the BC Centre for Excellence in HIV/AIDS (BC-CfE). “Improved patient support and education, as well as the availability of simpler and better tolerated HIV drug regimens, are likely contributors to the observed higher adherence and better outcomes.
The study’s main findings:
Individuals who start ART early are more likely to suppress the virus over time and maintain adherence levels over 95 per cent.
Individuals who start treatment at higher CD4 counts have the lowest probability of mortality and are less likely to develop drug resistance.
Between 2007 and 2012, comparing individuals with high and low CD4 counts on ART, the probability of mortality was lower amongst those with high CD4 at ART initiation.
Probability of loss to follow-up was lower among individuals with high CD4 starting ART in the most recent years, in comparison to the same group of individuals in previous years.
Bob Leahy: Hello Julio, thanks for talking to PositiveLite.com again. Now this new research from B.C is really interesting because we already know, particularly from START and Temprano about some of the real benefits of starting treatment early but now there are a few more that have been established. And I’m thinking that adherence is quite an important one. What’s your take?
Julio Montaner: Let me put this into context for you. There has been ongoing controversy as to whether or not patients who are asymptomatic and have a high CD4 count would be willing and able to adhere to and benefit from antiretroviral therapy in the long term. The argument was that if you are not driven by the urgency of CD4s or the like you would be unlikely to take treatment on a long-term basis. So while our feelings, based on the available literature, were known, we decided to conduct an analysis taking advantage of the fact that we have been offering treatment to people regardless of CD4 count in B.C. for a very long time. We basically showed that people who started treatment with very high CD4 counts were both willing and able to remain in treatment, even though they have occasional blips, as you would expect, from time to time.
And adherence is particularly important in the context of long term management of HIV.
Right, so for us it was critical to say that people are no more likely to leave treatment when they start treatment early.
I get that. Now this is B.C. research. Is it readily transferable to other jurisdictions. I’m thinking the BC environment, with free HIV meds and a long history of offering early treatment, is a bit different. Does that matter?
Let me answer that in two different ways. From a biological perspective I think that these results are reassuring and in keeping with the more recent results from the START and Temprano trials that show that individuals who have high CD4 counts actually have greater benefit than do people who defer treatment in terms of ultimate significant outcomes. Now for every jurisdiction the reality is that there will always be multiple factors, both subtle and obvious, that may contribute to the ability of people to draw wide-ranging conclusions. You could argue that there could be differential impact but I don’t have the ability to show that.
What about the impact of free HIV meds specifically?
In our (B.C.) environment we are enjoying fully subsidized antiretroviral therapy. Our position has always been, and remains quite forcefully, that any potential barriers to accessing antiretroviral therapy, including financial barriers, should be removed in order to ensure maximum and optimal sustainability of the effort. At the end of the day, not removing all barriers to immediate access to antiretroviral therapy, which we know is life-saving, life-prolonging and prevents transmission, would be highly detrimental to any program.
So you feel it would really help if other provinces were to embrace free access to HIV meds?
The failure to embrace free access to services including testing, engagement in care, support and treatment for all people infected with HIV or at risk for HIV is detrimental and in my opinion, very heavily discriminatory. What it systematically does is it punishes those in society most vulnerable over and beyond their vulnerability. For individuals like you and me who are socially, economically, intellectually and culturally privileged – all of those barriers may be of secondary importance because we have the means to overcome them. But as you move down the ladder of marginalization in our society, these barriers become exponentially more important. So, not surprisingly, we continue to witness the flourishing of the epidemic in areas around the country where programs have failed to embrace the kind of approach that I’m talking about. So it’s critical not just from a heath perspective, it’s critical from a human rights perspective.
I wanted to ask you Julio, you’ve long argued that early treatment was of benefit, both from a prevention angle and a health angle . . you took that early treatment position long before we had the conclusive evidence from START for instance, when other people were holding off on that conclusion. How were you able to do that?
Well, it would be easy for me to brag about it. All I have to say is that I have had the privilege to work with a group of individuals, a multi-disciplinary team who were able to put their contributions and interpretations of the date together, both domestically and internationally, and we were able to conclude that the overwhelming burden of evidence was in favour of early treatment. Now we recognize that we didn’t have all of the answers all of the time. But we also argued that in life, as it is in medicine, not having all the answers shouldn't preclude you from making the decision that is obvious and standing in front of you. It is incumbent on us to decide when the burden of evidence is enough to conclude that the status quo is no longer acceptable. So the default position became clear that we would not force people to take treatment but offer it. As data continued to accumulate from 2000 onwards, every step of the way we found more confirmatory evidence so that was very reassuring.
So with the emphasis on immediate treatment as opposed to early treatment, how do you feel about the need for extra precautions, extra safeguarding of civil rights to make sure there is no coercion and such? Do we have to do anything different that we haven’t done before?
Well, there is no doubt in my mind that there is a disconnect between how far medical science has gone and how far policy has gone, protecting the rights of individuals in the context of HIV and populations that are most at risk. The question becomes "can we move back to the default of not doing the right thing from a medical perspective because Ottawa or other jurisdictions in a position of power are failing to move in the right direction?" When we struggled with that we took a collective position in the province of British Columbia that we would move forward with the program recognizing that we enjoy a very favourable environment here policy-wise. Even though the laws of the land are the same as anywhere in the country, the actual enforcement of those laws is substantially different. Am I comfortable with the status quo? Absolutely not. I’ve been very vocal that we need policy reform federally to ensure that 90-90-90 can be met in an appropriate human rights framework. Am I going to wat for a new government, new policies, new everything before I can do the right thing? No, I can’t. We are going to work together with our communities to make the best out of a complex situation. But given what we know about the data from the START trial and others, I can not deny benefit to my patients because (Canadian Prime Minister) Stephen Harper will not do the right thing.
Well, there seems to be at least a movement towards early treatment in the provinces and I think START was instrumental in changing a lot of minds. But would pan-Canadian treatment guidelines be helpful to ensure everybody was on side and that patients reaped the benefits?
Well, as you know, I have year after year, starting with 2006, written to the Prime Minister and the federal Minister of Health, highlighting the need for pan-Canadian standards of care, including testing and offer strategies, and to the Public Health Agency of Canada, and all I get back from them is that “we will continue to watch your work with interest” but they are still, for political reasons, not able to fully embrace the kind of work that we have been doing.
How does all this fit in with 90-90-90 globally?
Well, we have got significant uptake of 90-90-90 targets but still jurisdictions across the country are trying to find a way around it, even after the 2015 IAS conference in Vancouver and the START trail results. It’s dumbfounding, but that’s the way it is. From my perspective the current national situation is rather disappointing, if not pathetic.
I hear you. We’ve been critical of the lack of a coherent national AIDS strategy too. Julio I want to thank you for this. You’ve been as frank and forthright as ever. It’s always good to talk to you.
You too. Bob.