The document discusses guidelines for starting HIV treatment and expanding testing and treatment efforts. It makes three key points: 1) Current guidelines recommend treating HIV when CD4 counts are below 350 or if patients have symptoms, and there is debate around treating above 500 CD4 counts. 2) Expanding universal, opt-out testing could increase the number of diagnosed patients by 25-50%, but there are concerns about the healthcare system's capacity to care for more patients. 3) Ensuring access to both medications and qualified providers will be important to providing effective HIV care for all patients.

1. Test and Treat:
Is it All Saints Day ?
or
Halloween?
Michael Saag, MD, FIDSA
University of Alabama, Birmingham
Director, Center for AIDS Research

2. 8 Year Survival in HAART Era
Updated from Chen, et al, 8th CROI, 2001

3. CD4 Count at HAART Initiation
Median % CD4 Median % CD4
CD4 < 200 CD4 < 200
1996 115 62.8% 2005 278 39.6%
1997 180 53.8% 2006 300 35.4%
1998 221 47.8% 2007 296 35.2%
1999 212 49.3% 2008 310 29.4%
2000 197 50.1%
2001 277 39.5%
2002 210 48.8%
2003 220 47.2%
2004 207 49.1%

4. Key Point:
Many (? Most) HIV infected patients in the
US don’t know they are infected
• Universal, opt-out testing is needed
Or is it….?

5. John Phillips: Libertarian
“You gotta go where you wanna go
Do what you wanna do
With whoever you
Wanna, wanna do it with….”

6. Slide 6
When To Start Treatment? –
Summary of Current Guidelines
Guidelines symptoms CD4 200- CD4 >350
or 350
CD4 <200
IAS-USA: treat treat Therapy should be
JAMA 2008 considered and
<www.iasusa. decision
org> individualized
DHHS: treat treat treat*
<www.aidsinfo.
nih.gov> * Split opinion > 500

7. Slide 7
When To Start Treatment? –
Summary of Current Guidelines
Guidelines symptoms CD4 200- CD4 >350
or 350
CD4 <200
IAS-USA: TREAT TREAT Therapy should be
JAMA 2008 considered and
<www.iasusa. decision
org> individualized
DHHS: TREAT TREAT TREAT*
<www.aidsinfo.
nih.gov> * Split opinion > 500

8. Slide 8
Reasons for Earlier Initiation of Therapy
 Cohort Study Results (NA-ACCORD /
ART-CC)
 Consequences of unchecked viral
replication (Inflammation / Harm)
 Improved tolerability / convenience of
newer ARV regimens
 Treatment reduces transmission of HIV
 Cost Savings

9. Slide 9
Relative Time on Treatment…
40 years on Rx
CD4 650/ul
35 years on Rx
5 years
CD4 500/ul
30 35 40 45 50 55 60 65 70
AGE (years)

10. Slide 10
Relative Time on Treatment…
40 years on Rx
CD4 650/ul HARM? 35 years on Rx
5 years
CD4 500/ul
30 35 40 45 50 55 60 65 70
AGE (years)

11. Slide 11
Most New Infections Transmitted by
Persons who Do Not Know Their Status
~25% account for…
Unaware
of
Infection ~54%
New
Infections
~75%
Aware
of
Infection ~46%
of New
Infections
Source: G. Marks et al. AIDS 2006

12. Slide 12
Prevention of Transmission
♦ TEST and TREAT
– Testing and Linkage to Care (TLC+)
National AIDS Strategy…

13. Blueprint for HIV Treatment Success
Retention in Care
Linkage ARV ARV Outcome
HIV Dx
to Care Receipt Adherence s
Adapted from: Giordano et al. Curr HIV/AIDS Rep 2005;2:177-183, Samet et al. AIDS 2001;15:77-85,
Eldred & Malitz. AIDS Pt Care STDs 2007;21:S1-2; Tobias et al. AIDS Pt Care STDs 2007;21:S3-8

14. Expanding the spectrum of adherence
Retention in Care
Linkage ARV ARV Outcome
HIV Dx
to Care Receipt Adherence s
One-third of pts. w/ known
HIV infection are not
engaged in care
25% of HIV-infected 20-40% of newly
individuals in the U.S. diagnosed pts. fail to
are undiagnosed establish care w/in 6 mos.
Glynn & Rhodes. National HIV Prevention Conference 2005, Abstract 595, Gardner et al. AIDS 2005;19:423-431,
Mugavero et al. Clin Infect Dis 2007;45:127-130, Fleming et al. 9th CROI 2002, abstract 11

15. Mean Annual Total Patient Costs
by CD4 Count (cells/ul)

16. Mean Annual Total Patient Costs
by Component

17. Key Points
• Mortality is much higher when patients are
diagnosed late in the course of infection (CD4 <
200 /ul)
• The majority (> 50%) of newly diagnosed patients
are diagnosed late (except preg Women)
• Many (? Most) HIV infected patients in the US
don’t know they are infected
• Universal, opt-out testing is needed
With more universal testing, a 25 -50% increase
in patient volume will occur

18. Who will take care of these
patients?

19. Provision of medications
• “Every American who needs HIV treatment
and care should have access to it”
• “People who are HIV-positive need
essential medications”
• “Without the drugs, providing care is
difficult to impossible”
PACHA. Achieving and HIV-Free Generation; IDSAnews 2006;16(1):7

20. Provision of HIV CARE
• “Every American who needs HIV treatment
and care should have access to it”
• “People who are HIV-positive need
essential medications”
• “Without the drugs, providing care is
difficult to impossible”
• “Without qualified HIV care providers and
clinics, HIV drugs mean nothing”
PACHA. Achieving and HIV-Free Generation; IDSAnews 2006;16(1):7

21. EDITORIAL COMMENTARY
Which Policy to ADAP-T:
Waiting Lists or Waiting Lines?
Michael S. Saag
University of Alabama at Birmingham Center for AIDS Research
Clinical Infectious Diseases 2006;43:1365-1367
© 2006 by the Infectious Diseases Society of America. All rights reserved.