HIV-positive persons now receiving treatment earlier

Jun 25, 2008 News

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By Melanie Allicock
Guyana has taken the crucial and controversial decision to have Persons Living with HIV/AIDS (PLWHA) begin receiving antiretroviral treatment earlier in their illness.

Health Minister Dr Leslie Ramammy has instructed that once an infected person shows signs of having an opportunistic infection they must be placed on antiretrovirals (ARVs) regardless of their CD4 counts.

At the moment, some HIV-positive patients that recorded CD4 counts as high as 500 are on treatment.

Minister Ramsammy made it clear that his decision is not in defiance of current international medical guidelines which lean towards waiting until an HIV-positive person’s CD4 count reaches around 350, but is adamant that waiting until an infected person has full blown AIDS to treat them, flies in the face of common sense and compassion.

He believes that economics played a vital factor in the decision made by World Health Organisation and other international health bodies ‘to wait’ since it would mean spending much more to treat patients earlier.

The Minister however counters that to not allow HIV-positive persons to access treatment early may very well result in greater health costs for a country.

“If you start PLWHAs on treatment early, yes, it would mean finding more money for drugs since more people will be on treatment, but on the other hand if you were to wait until their CD4 count reaches very low to treat them, when they become ill they will seek medical attention for the opportunistic infections, and this still translates into costs for the health sector and in some cases can even be more. So it balances out… these are some of the things that Guyana took into consideration in making this decision.”

Charting its own path as it relates to the treatment and care of PLWHAs is not new to Guyana.
Prior to turn of the century, Guyana did not have the capacity for CD4 testing prior to administering treatment as was required.

However this country was one of several which defied this, noting that it did not need a reading to begin treating persons.

So, once someone tested positive for HIV and had an opportunistic infection, they had access to treatment using the rationale that their immune system was impaired.

Then a few years ago when the international public health guidelines said preventive therapy should begin when an HIV-positive person who has no symptoms registers a CD4 count under 200, Guyana made the decision to change this to 350. 

At the time, the Centers for Disease Control and Prevention considered HIV-infected persons with CD4 counts below 200 to have AIDS, regardless of whether they were sick or well.

“I didn’t need the reading to tell me what to do. We changed it to 350 to be consistent with more developed countries,” the Minister said.

Another major rationale touted by the international health organizations for waiting until a person’s CD4 count dropped significantly was that they would develop resistance to the drugs.

However, Ramsammy noted that in Guyana’s context, resistance would develop much slower because we administer the antiretrovirals in a cocktail form rather than mono therapy.

Another reason given for the delay in treatment is liver toxicity of the patients but Minister Ramsammy reiterates that the benefits of starting treatment earlier far outweigh the risks
“The toxicity is not as high as people had predicted it to be … it was thought that if you took drugs for long it would affect your liver, but the evidence now suggests otherwise and therefore there is no reason why we should not treat people earlier…Why should we wait until people get sick, why cant we keep them healthy?” the Minister questioned.

He noted that at the moment Guyana is treating each HIV/AIDS case on its own merit. And while a time frame has not been specified for the onset of the treatment with the ARVs, the minister said it is a judgment call for doctors.

“Some people get sick when their CD 4 count reaches around 360 and others later. I’m saying that doctors must use their discretion.  The CD4 must not be the criteria for putting people on treatment but rather, should be used as a monitor of how well people are responding to the drugs.”

The Minister stressed that just like a patient would go to a doctor for diabetes and he would decide based on the person’s health whether he/she should be put on insulin, in like manner it should happen when a person living with HIV/AIDS visits the doctor.

“The physician must look at the general health of the patient and decide if he/she is susceptible.  
So at the moment it is possible that someone may have a CD4 count of 500 but comes in with an infection and is already having diarrhea and so we are going to treat them, we are not going to wait. On the other hand if someone comes in with a CD 4 count of 500 and is not having any problem other than having AIDS we will wait.”

As is expected, this new intervention has increased the number of people on treatment from 1,200 to 2,500 presently.

According to the Minister, there should be about 5,000 on treatment but this figure was stifled because the country was using the CD4 cut-off point.

He noted that the number of persons presently receiving treatment is expected to triple this year with the removal of the restriction.

The Human Immunodeficiency Virus (HIV) uses CD4 T-cells, a type of white blood cell that fights infection, to make copies of itself. This process destroys the CD4 T-cells, weakening the immune system.

The CD4 count indicates the strength of the immune system, how far the HIV disease has advanced (the stage of the disease), and helps predict the risk of complications and debilitating infections. The CD4 count is most useful when it is compared with the count obtained from an earlier test.

The CD4 count is used in combination with the viral load test, which measures the level of HIV in the blood, to determine the staging and outlook of the disease.

Normal CD4 counts in adults range from 500 to 1,500 cells per cubic millimetre of blood.

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