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Author Topic: Treatment as prevention  (Read 2274 times)

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Offline buginme2

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Treatment as prevention
« on: May 12, 2011, 07:58:10 PM »
With all ofthe discussions of when to start medication one major reason to start treatment right away is to lessen the spread of the disease.  Vancouver BC saw a 50% reduction when they implemented this policy.  Another study was recently halted 5 years early because the benefit of treating right away was clear and substantial.  Thoughts?

Source:

http://www.msnbc.msn.com/id/43006725/ns/health-aids/


Offline Matty the Damned

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Re: Treatment as prevention
« Reply #1 on: May 12, 2011, 07:59:41 PM »
Can we not lessen the spread of the disease by using condoms?

MtD

Offline buginme2

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Re: Treatment as prevention
« Reply #2 on: May 12, 2011, 08:11:56 PM »
We havent been able to do that so far. At least not in the United States.  The rate of new HIV infections has held steady at about 50,000 each year over the past 15 years. 

Offline Matty the Damned

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Re: Treatment as prevention
« Reply #3 on: May 12, 2011, 08:28:34 PM »
We havent been able to do that so far. At least not in the United States.  The rate of new HIV infections has held steady at about 50,000 each year over the past 15 years. 

Yeah. You can thank Jesus for that.

I understand the public health principle at work here. By making people less infectious through HAART we reduce the transmission rates.

This would require (in the States at any rate) much greater availability of HAART to the most vulnerable populations.

Greater availability of HAART would be a good thing.

Would, however, this approach to preventing transmission undermine safe sex efforts? HAART won't prevent the spread of other venereal diseases.

Also, should there be some sort of compulsion for positive people commence HAART if it is not otherwise contraindicated?

MtD

Offline buginme2

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Re: Treatment as prevention
« Reply #4 on: May 12, 2011, 08:36:30 PM »
Ya I don't know.  Espe ially in the US were so much is determined by the allmighty dollar I doubt the govt or insurance companies would pay earlier when is absolutely needed for the health of the patient.  However, in British Columbia when they implemented this they stated that in the long run they actually save money becAuse there were fewer infections.  Of course that requires foresight.

And yes. This does nothing in terms of your other run of the mill STD's.

Offline WillyWump

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Re: Treatment as prevention
« Reply #5 on: May 12, 2011, 08:54:52 PM »
It's a great idea, but it would never work here in the US given the sorry state of affairs ADAP is in  >:(

Wasn't this the brilliant idea Obama came up with "Treatment as Prevention"...oh but wait a minute, we cant even get all Americans treated yet.

-Will
« Last Edit: May 12, 2011, 08:57:36 PM by WillyWump »
POZ since '08

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Offline tednlou2

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Re: Treatment as prevention
« Reply #6 on: May 12, 2011, 11:34:29 PM »
The good number of gay men (speaking for the gays) just refuse to use condoms.  Straight guys don't like to use them either, but their risk of getting HIV is much lower.  The majority of str8 guys using them are probably very scared of finding out they have to pay child support for 22 years.  Having said that, I thought some study said teens were using condoms at higher rates now--more than older folks. 

I believe these studies only looked at heterosexual couples, right?  96% risk reduction?  Can we say magnetic couples can make their own decisions about whether to bareback and not say they are playing with fire, being selfish, putting their partner at serious risk, yada, yada?  We take risks everytime we leave our house.  It would seem the neg partner would be more likely to get killed in a car accident going to buy condoms than get HIV from bareback sex with a partner on ARV's with a longtime UD viral load--at least according to these studies.

Offline LM

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Re: Treatment as prevention
« Reply #7 on: May 13, 2011, 12:50:22 AM »
I'm bissexual, so from my experience I can say: if I wanted, I could have sex without condoms with most girls with no problems. Naturally, I won't do it, but straight couples are worried about pregnancy, that's about it, they rarely think of STDs. That's why I say: safe sex campaigns are effective until a certain point. People already don't like condoms, and besides, they are just tired of them.

Offline mecch

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Re: Treatment as prevention
« Reply #8 on: May 13, 2011, 05:44:54 AM »
A ID in Geneva told me many doctors in Paris and Geneva are persuaded by treatment as prevention, added to the benefits of early treatment, and this is why they routinely offer HAART regardless of the official treatment protocals.

Is there any country that pursues treatment as prevention?  

Still, there are so so so many issues around the idea of treatment as prevention its hard to imagine it ever becoming an officially announced nationwide "program" in some country.
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline edfu

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Re: Treatment as prevention
« Reply #9 on: May 13, 2011, 07:24:47 AM »
In San Francisco the Dept. of Public Health  recently adopted a policy of immediate treatment.  Most interestingly, though, the primary motivation is not prevention of infection but prevention of chronic inflammation in the already infected.

From "The New York Times:"

City Endorses New Policy for Treatment of H.I.V.
By SABIN RUSSELL
Published: April 3, 2010
 
In a major shift of H.I.V. treatment policy, San Francisco public health doctors have begun to advise patients to start taking antiviral medicines as soon as they are found to be infected, rather than waiting — sometimes years — for signs that their immune systems have started to fail.
 
The new, controversial city guidelines, to be announced next week by the Department of Public Health, may be the most forceful anywhere in their endorsement of early treatment against H.I.V., the virus that causes AIDS.

Ever since combinations of antiviral drugs were found to slow progression of the disease in the mid-1990s, doctors and patients have wrestled with the question of when to begin a lifetime regimen of costly and sometimes toxic medicines. The answer remains in dispute, but public health leaders here are now making a case for a change.

Behind the policy switch is mounting evidence that patients who start early are more likely to live longer, and less likely to suffer a variety of ailments — including heart disease, kidney failure and cancer — that plague long-term survivors. Studies suggest that in the early years of infection, when a patient may show few signs of immune system failure, the virus is in fact causing permanent damage that becomes evident later.

For instance, in older patients who finally start taking the drugs, the effects of chronic inflammation take their toll.

“The impact on health risk is comparable to that of diabetes,” said Dr. Steven G. Deeks, a researcher at the University of California, San Francisco. “Their immune system may look like that of someone 30 years older.”

Dr. Diane V. Havlir, chief of the H.I.V./AIDS division at San Francisco General Hospital, said the new policy was already in effect for her patients. Although a decision whether or not to take the medicine rests with the patient, all those testing positive for H.I.V. will be offered combination therapy, with advice to pursue it.

“The history of H.I.V. disease has always been about change,” she said. “We pride ourselves on working quickly with new data.”

At the public hospital’s H.I.V. clinic, a 30-year-old man is mulling advice from Dr. C. Bradley Hare to start on antiviral drugs. He was infected four years ago, but his T-cell count, a measure of infection-fighting white blood cells, is 735, comparable to that of an uninfected, healthy adult. He is buff and athletic and feels good.

The man has decided to keep waiting. “Once you start the drugs, you can’t stop,” he said. “You know how they say, ‘If it ain’t broke, don’t fix it?’ ”

Dr. Hare has been following research on early treatment, and for the last several years he has asked his patients to think about it. Now, he is recommending it outright. He said most of his patients did not have serious problems with drug side effects.

“A lot of times they have a sense of relief when they start the meds,” he said.

The turning point in San Francisco’s thinking may have been a study in The New England Journal of Medicine on April 1, 2009, that compared death rates among thousands of North American H.I.V. patients. Dr. Mari Kitahata, an epidemiologist at the University of Washington, and her team of researchers found that patients who put off therapy until their immune system showed signs of damage had a nearly twofold greater risk of dying — from any cause — than those who started treatment when their T-cell counts were above 500.

There is another motivation prompting the change. Reducing the level of virus in the population of infected people may reduce the spread of the disease.

“I do anticipate it will drive down the rates of new infections,” Dr. Mitchell H. Katz, San Francisco director of public health, said. “It’s a nice, secondary benefit of this new policy.”

Dr. Katz said that despite cuts in health budgets, a policy to add to the number of H.I.V. patients taking expensive drugs made economic sense. “H.I.V. medications have been continually proven to be cost effective,” he said, “and in this case, it is also the right thing to do.”

The program is being carried out without a clear picture of its cost to city and state health agencies. Antiviral drugs can cost $12,000 a year, consuming $350 million of the budget of California AIDS Drug Assistance Plan.

Dr. Michelle Roland, chief of the state’s Office of AIDS, said she and her counterparts across the country were working with the Centers for Disease Control and Prevention to estimate the added cost of early treatment.

In San Francisco, up to 2,000 people know they are H.I.V. positive, have healthy T-cell counts and are not yet on treatment, according to the city. Cost estimates are complicated by unknowns, like the number of patients choosing to participate, how close they were to needing treatment under the previous system and whether they had private insurance.

When the first combinations of AIDS drugs came out in 1996, the thinking was “hit early, and hit hard.” But as patients battled nasty side effects, like diarrhea and disfiguring shifts in body fat, therapy was deferred until T-cell counts fell as low as 200.

Today, with safer drugs, quick viral suppression is back in fashion.

“The field is moving, inexorably, to earlier and earlier therapy,” said Dr. Anthony Fauci, director of the National Institutes for Allergy and Infectious Diseases. He called San Francisco’s decision “an important step in that direction.”

But the proposal is highly controversial, even in San Francisco.

“It’s just too risky,” said Dr. Jay Levy, the U.C.S.F. virologist who was among the first to identify the cause of AIDS. The new drugs may be less toxic, Dr. Levy said, but no one knows the effects of taking them for decades.

San Francisco’s decision follows a split vote in December by a 38-member federal panel on treatment guidelines. Only half of the H.I.V. experts gathered by the Department of Health and Human Services favored starting drugs in patients with healthy levels of more than 500 T-cells.

One panel member, James D. Neaton of the University of Minnesota School of Public Health, contends that a rigorous, randomized clinical trial is needed to show whether early intervention works. The risks of early treatment — giving powerful drugs to people at low risk of disease — - could outweigh the “modest predicted benefit,” Dr. Neaton wrote in an e-mail message. “That is why we do randomized trials.”

In 2009, the University of Minnesota began a study to find that proof. Results are expected in 2015.

Dr. Lisa C. Capaldini, who runs an AIDS practice in the Castro district, also has strong reservations. “H.I.V. behaves differently in different people,” she said.

Although Dr. Capaldini recognizes that today’s drugs are a vast improvement over earlier therapies, the program, she said “is not ready for prime time.”

But the changes make sense to Dr. Stephen Follansbee, director of H.I.V. Services for Kaiser Permanente in San Francisco, who oversees a program that covers 2,100 people with the virus.

“The idea of living in happy symbiosis with this virus is delusional,” Dr. Follansbee said. “If you have a fire in one part of the house, but not in the living room, you don’t wait for it to reach the living room before you call the fire department.” 
"No one will ever be free so long as there are pestilences."--Albert Camus, "The Plague"

"Mankind can never be free until the last brick in the last church falls on the head of the last priest."--Voltaire

Offline bufguy

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  • Posts: 161
Re: Treatment as prevention
« Reply #10 on: May 20, 2011, 01:25:23 PM »
From my reading, very few people do not proceed along the path of higher VL and lower CD4 counts. I know there are some "elite controllers" and "long term non progressors" but not many. Many progress to needing meds in only a few years. It also appears that the immflamation created by higher viral loads of HIV is a contributor to health problems such as cardiovascular and cancer.
That being said, over a lifetime how much harm could starting early, which may mean only a few years extra of meds over a 50 year span harm a person.
I started right away with a CD4 of 511 and have no regrets....3 years next week. Without meds I think my CD4 would have probably continued to drop jepordizing my long term health....for what? maybe 2 extra years of no meds.
5/29/08 confirmed HIV+
6/23/08 Vl 47500  CD4 511/29% CD8 .60
start atripla
8/1/08 Vl 130  CD4 667/31% CD8 .70
9/18/08 Vl un  CD4 not tested
12/19/08 Vl un CD4 723/32% CD8 .80
4/3/09 Vl un CD4 615/36% CD8  .98
8/7/09 vl un CD4 689/35% CD8 .9
12/11/09 vl un CD4 712/38% CD8 .89
4/9/10 vl un CD4 796/39% CD8 1.0
8/20/10 vl un CD4 787/38% CD8 1.0
4/6/10 vl un CD4 865/35% CD8 .9
8/16/10 vl un CD4 924/37% CD8 1.0
12/23/10 vl un CD4 1006/35% CD8 .9
5/2/10 vl un CD4 1040/39% CD8 .9
8/7/13 vl un CD4 840/39% CD8 .9

Offline newt

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Re: Treatment as prevention
« Reply #11 on: May 21, 2011, 06:37:14 AM »
Quote
Is there any country that pursues treatment as prevention?

All countries doing mother-to-child prevention programmes, for a start.

London has quietly introduced a pilot called "Intensive Combination Prevention" for (HIV-negative) gay men testing positive for an acute STI and/or had unprotected anaul sex with an HIV-positive/unknown status regular partner and/or unprotected anal sex with a casual partner. This involves having regular, rather than occasional, check-ups and HIV tests (at least 4 x year), a standardised interpersonal intervention based on motivational interviewing and a pack with antetrovial PrEP in it (Truvada I think).

People wanting to go on treatment to reduce the risk of transmission to their partner(s) is guideline compliant in the UK, and I know several people who have opted for this, both men and women.

- matt
"The object is to be a well patient, not a good patient"

Offline Ann

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Re: Treatment as prevention
« Reply #12 on: May 21, 2011, 07:54:55 AM »
I started right away with a CD4 of 511 and have no regrets....3 years next week. Without meds I think my CD4 would have probably continued to drop jepordizing my long term health....for what? maybe 2 extra years of no meds.

Bufguy, I'm curious. Had you been testing regularly before you got your positive result? I'm asking because looking at your numbers when you were first diagnosed, it is totally possible that you had been infected for a few years before you found out. Your numbers are not typical of a recent infection. What I'm trying to say here is that it looks as though you could well have had a stable infection and when you say you "started right away", that may not be as true as it feels or appears. Please don't feel like I'm "getting on your case", I'm seriously just curious as to your testing history before you got the positive result. :)
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"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Offline bufguy

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Re: Treatment as prevention
« Reply #13 on: May 23, 2011, 10:07:50 AM »
You are right Anne, I may have been infected years before...I had not tested in over 5 years. Starting right away I meant after diagnosis.
My doc suggested I start right away after my diagnosis. He told me I was well informed about HIV and was confident I would be adherent...which I am.
For me it was the right decision. I feel much more in control. Let's face it, there is an inevitability with the vast majority of people infected that they will need meds. I chose sooner than later.

As for "getting on my case"...no worries. I have so much respect for you Anne and your work here...I'm actually honored you responded.  :-)
5/29/08 confirmed HIV+
6/23/08 Vl 47500  CD4 511/29% CD8 .60
start atripla
8/1/08 Vl 130  CD4 667/31% CD8 .70
9/18/08 Vl un  CD4 not tested
12/19/08 Vl un CD4 723/32% CD8 .80
4/3/09 Vl un CD4 615/36% CD8  .98
8/7/09 vl un CD4 689/35% CD8 .9
12/11/09 vl un CD4 712/38% CD8 .89
4/9/10 vl un CD4 796/39% CD8 1.0
8/20/10 vl un CD4 787/38% CD8 1.0
4/6/10 vl un CD4 865/35% CD8 .9
8/16/10 vl un CD4 924/37% CD8 1.0
12/23/10 vl un CD4 1006/35% CD8 .9
5/2/10 vl un CD4 1040/39% CD8 .9
8/7/13 vl un CD4 840/39% CD8 .9

Offline Ann

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Re: Treatment as prevention
« Reply #14 on: May 23, 2011, 11:36:38 AM »

For me it was the right decision.


I'm glad you're happy with your decision and that things are going well for you. And thank you for clarifying your situation regarding testing. I can be nosy at times so I'm glad you didn't take offence. :)
Condoms are a girl's best friend

Condom and Lube Info  



"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

 


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