What Works for Women and Girls

HIV Prevention Is Needed as well as Universal Access to TreatmentUniversal access to antiretroviral therapy in low-income countries can be achieved. A numberof countries from Brazil to Ethiopia to Thailand are achieving progress in increasing thenumbers of those initiating ARV treatment at recommended CD4 thresholds (Messou et al.,2008, Marcellin et al., 2009, The ART-LINC Collaboration of the International Databases toEvaluate AIDS (IeDEA), 2008, Kloos et al., 2007, WHO, 2007c). Studies in Tanzania andKenya have shown that treatment, including the availability of fixed-dose combination antiretroviraltherapy, can also be effectively used for children in resource-poor settings with goodoutcomes in CD4 counts and nutritional status (Ble et al., 2007; Nyandiko et al., 2006; Jadhavet al., 2008; Calmy et al., 2006).WHO has issued new guidance to initiate treatment for those whose CD4 counts are below350, raising this level from earlier guidance that recommended initiating treatment when CD4counts went below 200 (WHO, 2009j). However, the optimal time to initiate treatment isstill a subject of considerable debate. Guidelines from the U.S. and Europe now recommendconsidering initiation of treatment when CD4 counts are between 350 and 500 (Wilken andGlick, 2008 cited in Dieffenbach, 2009). Recent studies in developed countries have foundthat patients starting antiretroviral treatment with CD4 counts greater than 350 are significantlymore likely to achieve normalized CD4 counts than those starting later (Gras et al.and the AIDS Therapy Evaluation Project (ATHENA), 2007; Moore and Keruly, 2007 citedin Dieffenbach, 2009). A large clinical trial of 8,362 in the U.S. and Canada found a 69%higher risk of death for patients who deferred rather than initiated antiretroviral therapy at aCD4 count between 351–500 (Kitahata et al., 2009). 1 However, “whatever the side effects ofHAART, side effects are not as deleterious as untreated HIV infection” (Sax and Baden, 2009:2). 2 It is clear that there still is a paucity of data from developing countries on early initiationof treatment at CD4 counts over 350. A randomized clinical trial started in March 2009 withsites in 23 countries in North and South America, Europe, Africa, the Middle East and Asiais assessing whether immediate initiation of antiretroviral treatment is superior to deferral oftreatment until the CD4 count declines to below 350. The pros and cons on initiating treatmentwhen CD4 counts are over 350 must be weighed (Dieffenbach, 2009). [See also Chapter9C-2. Safe Motherhood and Prevention of Vertical Transmission: Treatment]Progress is being made with treatment access. However, caution is warranted. …Mathematical modeling using surveillance and census data between 1986 and 2004 fromUganda found that as a result of population growth, by 2008, a similar number of peoplewill be HIV-positive (1.1 million) as during the peak of the epidemic in 1994. More effectiveprevention programs are still needed (Hladik et al., 2008a). A recent consultation at WHO in1 Note: As this is a new study, it is unclear how this will change clinical guidelines in the U.S. and Canada, aswell as whether WHO will revise guidelines and whether patients in developing country contexts will be able toinitiate treatment earlier.2 Study authors receive consulting fees from many of the companies who manufacture and market antiretroviraltherapy drugs. The funding for the study, however, came from NIH and other U.S. government agencies.WHAT WORKS FOR WOMEN AND GIRLS171