Friday, March 27, 2009

ARV Therapy and HIV Elimination

I'm waiting for my train in Ernakulum in an internet cafe that must be 40 degrees C. While sitting here sweating, I noticed a January 2009 Lancet article that has generated a lot of debate. The article (vol 373, issue 9657: 48-57) uses a theoretical model to asses whether testing everybody for HIV, then starting all positives on immediate ARV would eliminate HIV. [Note that the word "eliminate" does not mean the same as eradicate. They define eliminate as incidence of transmission less than 1 case per 1000 per year.] The idea of treatment as prevention is not new, of course, but this article takes it to the extreme. From the accompanying editorial:

In The Lancet today, Reuben Granich and colleagues (including two of us, KMDC and CFG) use mathematical modelling to assess the impact of expanded HIV testing and earlier antiretroviral therapy (ART) on HIV transmission.1 These researchers evaluated a theoretical programme of annual universal HIV testing and immediate treatment on HIV diagnosis, irrespective of CD4+ cell count, in an HIV epidemic with southern African population dynamics. The exercise suggested that HIV transmission could be substantially reduced within a few years. Elimination of HIV transmission, defined as an incidence below one case per 1000 population per year, could be achieved within a decade, and the overall prevalence of HIV infection reduced to below 1% before the middle of the century. Compared with current practice of starting ART at a specific CD4+ count, deaths would be halved between now and 2050.


The article generated a lot of interesting correspondence, some of which is published in vol 373, 9669. For me, the most important issue was raised in the letter by Jaffe et al:

In their important and provocative article,1 Reuben Granich and colleagues argue that universal voluntary HIV testing and immediate antiretroviral therapy, irrespective of the degree of immune suppression, could eliminate HIV from countries where the infection is highly prevalent. However, we agree with Geoffrey Garnett and Rebecca Baggaley2 that this approach could strongly shift the benefits of treatment from the individual to the population.

Although current HIV treatment guidelines favour earlier treatment, the risks and benefits of treatment for people with CD4+ cell counts above 350 per μL are unknown. Trials of therapy for patients with higher counts are yet to begin.

Within the field of communicable diseases, we are aware of little precedent for the approach of “treating for the common good”. Treatment of diseases such as tuberculosis might have the effect of decreasing transmission, but the primary goal is to decrease morbidity and mortality for the affected person. A better analogy might be found in immunisation programmes—eg, rubella vaccination of infants and children aims to reduce exposure among pregnant women. However, there is still a clear benefit and minimal risk for the individual vaccinee.

The World Medical Association international code of medical ethics states that “A physician shall act in the patient's best interest when providing medical care.”3 If we are to deviate from this basic principle, we will need a robust ethical model for balancing individual and societal benefits.

9 comments:

audra said...

I think the Western mind is very out of balance when considering the duality of individual v. community identity (weighted almost entirely towards the individual, to our own detriment). I suspect in the affected regions of Africa, people have a much stronger sense of their identity as part of a community, and may weigh the risks against the benefits with a very different scale.

Anonymous said...

[url=http://community.bsu.edu/members/buy+online+Viagra.aspx]Viagra with overnight fedex[/url]

[url=http://eterporno.ru/web-sayty-znakomstv.php]web сайты знакомств[/url]
[url=http://eterporno.ru/loveplanet-ru-znakomstva.php]loveplanet ru знакомства[/url]

[url=http://pc.eterporno.ru/ischu-parnya-dlya-seksa-v-odincovo.php]ищу парня для секса в одинцово[/url]
[url=http://pc.eterporno.ru/snyat-prostitutku-na-dom.php]снять проститутку на дом[/url]

[url=http://pv.eterporno.ru/trans-intim-dosug.php]транс интим досуг[/url]
[url=http://pv.eterporno.ru/znakomstva-g-usinsk.php]знакомства г усинск[/url]

[url=http://px.eterporno.ru/prostitutki-moskvy-deshovye-vyezd.php]проститутки москвы дешовые выезд[/url]
[url=http://px.eterporno.ru/intim-znakomstva-novgorod-novost.php]интим знакомства новгород новость[/url]

[url=http://pz.eterporno.ru/ulichnye-prostitutki-pitera.php]уличные проститутки питера[/url]
[url=http://pz.eterporno.ru/sayt-znakomstva-moskva.php]сайт знакомства Москва[/url]
[url=http://pz.eterporno.ru/blyadi-chelnov.php]бляди челнов[/url]

Anonymous said...

[url=http://www.blingforfun.com]hip hop jewelry[/url],[url=http://www.blingforfun.com/pendants/cat_9.html]hip hop pendants[/url],hip hop watches,[url=http://blingforfun.com/belts/cat_18.html]bling bling[/url] ,hip hop,[url=http://blingforfun.com/chains/cat_7.html]hip hop chains[/url],hip hop bling,[url=http://blingforfun.com/chains/cat_7.html]iced out chains[/url],[url=http://www.blingforfun.com/chains/cat_7.html]wholesale chains[/url]
hip hop jewelry
wholesale hip hop watches
hip hop rings

Anonymous said...

[color=#fffafa]
Не знаеш как пройти в
библиотеку не попав под машину? мм.. есть мега предложение по[url=http://www.pi7.ru] видео[/url] порталу Думаю вам понравится

[url=http://www.pi7.ru]малолетки в сперме[/url]
aнекдот для разнообразия :)

Всстречааются 2 подружки.
- Привет, Светка, как делишки?
- Да неплхоо, Катя, только без коцна живот болит..
- в, это хыйня, я например без конац вообще жить не могу.

Я 9 часов блуждала по сеит, пока не вышеал на ваш форум! Думсаю, я здесь останусь надолго!
прошу прощенияы за опечатки.... очепь маленькая клавивтура у PDA!

[/color]

Anonymous said...

Hello,

When ever I surf on web I never forget to visit this website[url=http://www.weightrapidloss.com/lose-10-pounds-in-2-weeks-quick-weight-loss-tips].[/url]whatonearthamidoinghere.blogspot.com really contains lot of useful information. Frankly speaking we really do not pay attention towards our health. In plain english I must warn you that, you are not serious about your health. Recent Research displays that nearly 50% of all USA adults are either fat or overweight[url=http://www.weightrapidloss.com/lose-10-pounds-in-2-weeks-quick-weight-loss-tips].[/url] Hence if you're one of these individuals, you're not alone. Its true that we all can't be like Brad Pitt, Angelina Jolie, Megan Fox, and have sexy and perfect six pack abs. Now the question is how you are planning to have quick weight loss? [url=http://www.weightrapidloss.com/lose-10-pounds-in-2-weeks-quick-weight-loss-tips]Quick weight loss[/url] is really not as tough as you think. Some improvement in of daily activity can help us in losing weight quickly.

About me: I am author of [url=http://www.weightrapidloss.com/lose-10-pounds-in-2-weeks-quick-weight-loss-tips]Quick weight loss tips[/url]. I am also health expert who can help you lose weight quickly. If you do not want to go under painful training program than you may also try [url=http://www.weightrapidloss.com/acai-berry-for-quick-weight-loss]Acai Berry[/url] or [url=http://www.weightrapidloss.com/colon-cleanse-for-weight-loss]Colon Cleansing[/url] for effective weight loss.

Anonymous said...

Hey,

Do you guys watch movies in theater or on internet? I use to rent DVD movies from [b]Bigflix.com[/b]. Recently I discovered that we can watch all new movies on internet on day, they are released. So why should I spend money on renting movies??? So, can you guys please tell me where I can [url=http://www.watchhotmoviesfree.com]watch latest movie Going the Distance 2010[/url] for free?? I have searched [url=http://www.watchhotmoviesfree.com]Youtube.com[/url], [url=http://www.watchhotmoviesfree.com]Dailymotion.com[/url], [url=http://www.watchhotmoviesfree.com]Megavideo.com[/url] but, Could not find a good working link. If you know any working link please share it with me.


Thanks

Anonymous said...

развлечения в новейшее время

в [url=http://goooogl]Gooogle[/url] знакомства в kраснодаре
знакомства для секса на ночь Морозовицы

Anonymous said...

of course like your website however you need to test the spelling on
quite a few of your posts. Many of them are rife with spelling issues and I find it
very bothersome to inform the reality on the other hand
I'll certainly come back again.

Also visit my web site; Acai Ultra Lean Diets

Anonymous said...

Somebody essentially assist to make critically articles I'd state. That is the first time I frequented your web page and to this point? I amazed with the research you made to create this particular put up incredible. Magnificent task!

123 income academy