The UN's World Health Organisation (WHO) on Monday issued the first overhaul of its guidelines on HIV drugs in four years, saying the therapy now saving more than five million lives should be initiated at an earlier stage of infection.
A phonebook-sized volume issued at the International AIDS Conference in Vienna confirmed and amplified a key recommendation made by the UN agency last year about earlier use of antiretroviral therapy (ART).
The 156-page report highlighted the leading role played by the famous drug "cocktail" in fighting the human immunodeficiency virus (HIV) which causes AIDS.
The combination therapy, which was first introduced in 1996 but initially restricted to rich countries because of its then high cost, reached 5.2 million people in 2009, an increase of 1.2 million over 2008, the report said.
At least 4.3 million other poor, badly-infected people still need access to the treatment, according to a 2008 count.
In 2006, the WHO advised drug initiation when the tally CD4 cells -- the key immune cells targeted by HIV -- reached 200 cells or less per microlitre of blood, a stage that meant a patient's immune system had already been badly weakened by the virus.
In 2009, citing evidence about the drugs' effectiveness and safety, the agency raised the figure to 350 CD4 cells per microlitre of blood, which thus means at an earlier stage of infection.
This recommendation is spelled out in the new report, along with many other guidelines on drug use, including second-line therapy if a first course of treatment fails.
"All adolescents and adults including pregnant women with HIV infection and CD4 counts of 350 cells/mm3, should start ART, regardless of the presence or absence of clinical symptoms," said the report.
"Those with severe or advanced clinical disease (WHO clinical stage three or four) should start ART irrespective of their CD4 cell count."
First-line therapy should consist of a simplified, low-toxicity regimen of drugs aimed at key enzymes that help the virus to replicate in CD4 cells, the WHO said.
The combination should comprise one non-nucleoside reverse transcriptase inhibitor (NNRTI) and two nucleoside reverse transcriptase inhibitor (NRTIs), one of which should be zidovudine (AZT) or tenofovir (TDF).
"Countries should take steps to progressively reduce the use of stavudine (d4T) in first-line regimens because of its well-recognized toxicities," the WHO cautioned.
The UN's recommendation of 350 CD4 cells per microlitre of blood compares with advice of 500 CD4 cells, or below, issued on Sunday by a separate panel just before the six-day 18th International AIDS Conference began.
The threshold, proposed by the US branch of the International AIDS Society (IAS), is applicable mainly to rich countries that have the budget and infrastructure for treating people earlier, the panel said.
ART can reduce levels of HIV to below detectable levels, although does not eradicate the pathogen completely, and for many patients carries toxic side effects, ranging from nausea and cramps to redistribution of fat around the body.
The longer-term impacts of this powerful therapy are also not fully known.
Guideline revisions have an enormous impact, both for new patients and health budgets.
Earlier initiation means that people will be exposed longer -- about one or two years more, said the report -- to ART's side effects and the risk of viral resistance.
The new report, Antiretroviral Therapy for HIV infection in Adults and Adolescents: Recommendations for a Public Health Approach, will be next updated in 2012, the agency said.
At least 25 million people have died of acquired immune deficiency syndrome (AIDS) since the disease first came to light in 1981.
At the end of 2008, more than 33 million people had HIV, and 2.7 million people that year became infected, according to UNAIDS.
ri/dk
COPYRIGHT 2002 Agence France-Presse. All rights reserved.