Dr. Sax: Well, the latest Department of Health and Human Services guidelines, which were updated last in February of 2013, state that antiretroviral therapy is recommended for all HIV-infected individuals to reduce the risk of disease progression.1 Now, the strength of this recommendation varies based on the CD4-cell count.
Narrator: Specifically, there is greater urgency in starting antiretroviral therapy in someone with a CD4-cell count of less than 350 cells/mm3 versus someone with a higher CD4-cell count of greater than 500 cells/mm3.
Dr. Sax: So in those patients who fall into the former category, starting antiretroviral therapy is [a] time-sensitive priority. For those in the latter category, it is less important that it be done immediately, but certainly antiretroviral therapy still could benefit that individual.
Narrator: Ongoing research3 will further evaluate the use of immediate versus delayed antiretroviral therapy in patients with CD4 counts greater than 500 cells/mm3. Furthermore, clinicians should consider comorbid conditions and the willingness and readiness of the patient to start therapy when making decisions about initiating antiretroviral therapy.
Dr. Sax: The guidelines also state that antiretroviral therapy is recommended for HIV-infected individuals for the prevention of transmission of HIV.1 This additional benefit of HIV therapy is something that emerged in Study [HPTN] 052, which was published in 2011, and it demonstrated a 96% reduction in the risk of transmission from an infected person to an uninfected person, in a prospective, randomized clinical trial.4
Now, all of these recommendations for HIV therapy for all patients could not really take place unless there had been substantial progress in the success of HIV treatment. I think it's useful to look at two studies that really highlight this progress, both done in Baltimore out of the Johns Hopkins HIV program. In 1999, a paper was published showing that the virologic suppression rates in patients in this clinic from 1996 to 1998 were only 37%.5 By contrast, a paper was published in 2011 showing that the rate of virologic suppression is now 87% among those prescribed treatment.6
So the vast majority of people who are prescribed HIV therapy and who show up for their regular outpatient care are successfully treated, which means that we can be confident that, if people take the medications that we are prescribing today, they will most likely virologically suppress. Those who do not have successful treatment are, by and large, those who have very poor medication adherence. And that is still a challenge, but it's in a minority of patients.