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Will new WHO guidelines reduce HIV-related illness burden?

Just more than a decade ago, World Bank (WB) health specialists told India that anti-retroviral (ARV) treatment, the only lifesaver for people living with HIV, should not be its priority because it would exhaust the country’s health budget.

The then National AIDS Control Organisation (NACO) mandarins also parroted what the WB and the West-funded international community told them when AIDS-activists clamoured for treatment after seeing the miraculous recovery people were making with ARV in the developed world.

HO now says that more people, who had hitherto not been advised to start ARV, should also be put under treatment, which means people should go on treatment much earlier than before. AFP

HO now says that more people, who had hitherto not been advised to start ARV, should also be put under treatment, which means people should go on treatment much earlier than before. AFP

The response to them was something like this: "You are bloody poor and cannot afford treatment. We cannot do anything for you; let’s think about preventing new infections and protecting others."

Then CIPLA, generics and Clinton Foundation happened even as the naysayers continued their health economics spiel that ARV was way too expensive for the poor in hopeless countries such as India. In no time, the CIPLA magic took over the world and the treatment-denialists became treatment-activists.

MNC drug companies still tried to operate through the international experts because nobody could afford their drugs in India; and for them, encouraging treatment in India would have encouraged generics.
But the tide of generics and treatment activism drowned their plot in no time.

Ironically, some of those no-treatment advocates made fantastic careers in AIDS-treatment and human rights bureaucracy after their retirement from government offices where they blocked ARV. Even some vocal international NGO-leaders, who thought ARV was impossible for countries such as India, became treatment and rights evangelists in multilateral bureaucracies.

Why such an update on ARV-history?

Because on 30 June, the WHO has revised its ARV guidelines which make AIDS-treatment more universal. WHO now says that more people, who had hitherto not been advised to start ARV, should also be put under treatment, which means people should go on treatment much earlier than before.

WHO’s new "Consolidated guidelines on the use of anti-retroviral drugs for treating and preventing HIV infection" asks all countries to start ARV for people living with HIV whose CD4 count is 500. CD4 is a marker for immunity in people living with HIV; the lower it gets, the sicker they get.

Earlier, the WHO had advised people to start ARV when the CD4 dropped below 300, the threshold when people fell ill. In the initial years, it was even lower — for some it was 200 and some, 250, by which time some people might have already fallen sick. Even 300 was an optimal barrier because some people fell sick to various infections before the CD4 reached there.

The new standard of CD4 500 makes it incumbent on countries to give ARV to its HIV-positive people much earlier, long before their immunity is compromised. Scientific evidence shows that starting treatment early has tremendous benefits, particularly in keeping their immune systems healthier, if not intact.

What is the significance of these new guidelines?

If countries can comply with them, we might see many people living with HIV not falling sick at all, at least for several (more) years after they get infected. It will reduce the burden of illnesses such as TB and other infections, morbidity and even deaths.
AIDS will finally get a real make-over as a chronic condition such as diabetes.

Besides reducing sickness in people living with HIV and extending their lifespans dramatically, early treatment has many other benefits. One of them is substantial reduction of HIV-transmission. ARV reduces the load of the AIDS-causing virus in the blood, thereby reducing its transmission to others. If one starts early, the transmissibility of the virus is also reduced early. Over a period of time, the pool of infection and transmission come down to such a level that the epidemic gets reversed.

Another recommendation of the WHO is to take a single-dose combination pill, which is as convenient as taking medicines for chronic conditions such as diabetes and hypertension.

Commenting on the new guidelines, WHO Director General Dr Margaret Chan admits that such a step was “unthinkable just a few years ago” and can “fuel the momentum to push the HIV-epidemic into an irreversible decline”. A few countries such as Algeria, Argentina and Brazil have already begun to treat PLHIV with a CD4 count of 500.
However, early treatment and more people on treatment, has its challenges in countries such as India. The most critical of them is drug-resistance because of possible mismanagement and irregular treatment.

At present India’s ARV coverage is only about 30 percent, which means raising the CD4 bar to 500 makes it even less. If the government raises the coverage by even a few percentage points, it will translate into thousands of more people. And all these people are also potential sources, or victims, of drug resistance.

More people coming into treatment increases the threat of the drug-resistance burden, particularly with poor treatment-literacy, constant stock-outs and overall poor culture of treatment-adherence. The incidence of drug-resistant TB and other antibiotic-resistant illnesses in India are scary indicators of a sub-epidemic of drug-resistant HIV.

From no treatment, to some treatment and now more treatment — and the evolution of the science behind the ARV-philosophy has brutally defeated the original technical advise of the international experts that shaped the policies of countries such as India.

One can argue that people can make mistakes in evolving and uncertain situations, but the point here is the audacity with which these experts speak down to countries such as India and the meekness with which our bureaucracy buys it. And this is the biggest problem with massive loans from World Bank and ADB because they come with their absolute wisdom.