In an article entitled “Millions More Need H.I.V. Treatment, W.H.O. Says,” NY Times writer Donald G. McNeil Jr. explains the implications of the new WHO HIV Treatment and Prevention Guidelines. Previously, those living with HIV were put on antiretroviral therapy (ART) once their CD4 cell count, which is essentially used as a measure of the strength of one’s immune system, declined to a certain level. Now, the new guidelines recommend ART to everyone who is HIV positive, regardless of their CD4 cell count. In addition, the guidelines recommend that more people use a daily oral pre-exposure prophylaxis (PrEP) as a preventative measure. PrEP reduces the chance of acquiring HIV even in the case of exposure to the virus. Therefore, PrEP is highly recommended to those who are at a higher risk of being exposed to HIV, such as gay men, sex workers, and people who have HIV positive partners. The new guidelines recommend this preventative measure to more people than did the previous guidelines, including African women and children. Under these new guidelines, nine million more people should be treated with ART and “untold millions” more should use PrEP.
These new guidelines are backed up by a substantial amount of evidence that they will prove to be effective. According to the WHO, there have been numerous clinical trials, observational studies, and other research released since 2013 that back up both the earlier initiation of ART and the success of PrEP as prevention. In addition, HIV/AIDS experts, such as Dr. Mark Dybul (executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria) and Dr. Deborah L. Birx (the United States global AIDS coordinator and head of the President’s Emergency Plan for AIDS Relief), support the new guidelines. The Centers for Disease Control and Prevention (CDC) is also a strong source of support for the treatment and prevention combination, and some North American cities have implemented this combination before, to great success.
McNeil raises salient questions throughout his article: how much will it cost to implement these new guidelines? How will those costs be paid? He points out that, not only are the drugs themselves expensive, but a substantial amount of money must go into the health care systems needed to administer those drugs. According to the article, there have not yet been any widely accepted estimates of the cost of these new guidelines; however, some say that current HIV treatment costs would at least triple, with prevention likely costing exceedingly more.
I agree with McNeil. These new guidelines sound wonderful. This combination of ART for treatment and PrEP for prevention has been proven to work, so I would not classify this as excessive treatment or prevention. This is especially true for the treatment: according to the WHO, initiating ART earlier results in better clinical outcomes for HIV positive patients than waiting for their CD4 cell counts to get low enough to start treatment. Recommending that African women and girls use PrEP as a preventative measure is also extremely important, as they are a major at-risk population for HIV infection. That said, before these new guidelines are fully implemented, the issue of cost must be thoroughly examined, and, according to the article, that issue is being largely ignored presently. In countries without universal healthcare coverage, people living with HIV often cannot afford their medications without sufficient health insurance, and that may apply to those at risk for contracting HIV, especially if their insurance provider deems them “not enough at risk” and denies coverage. Even countries with universal healthcare must grapple with the higher bill, and we all must consider where payment will come from in the case of low- and middle-income countries that cannot afford the medications on their own. With these new guidelines, everyone involved with healthcare and the HIV/AIDS epidemic, including governments, organizations like the Global Fund, insurance providers, patients, etcetera, all must closely examine the major problem of cost in this situation.