The summit wasn’t all about HIV testing, and several sessions on Friday tackled other pressing issues.
One was when to start testing someone who is infected. Dr. Veronica Miller, executive director of The Forum for Collaborative HIV Research, framed the issue for a panel of experts.
``A big question is why don’t we just put them on treatment right away? There is a lot of enthusiasm for that idea, but what evidence will that policy be based on?'' she said.
Two panel members discussed clinical trials still in their relative infancy, while a third gave a cost-effectiveness perspective. AIDS physicians now routinely start anti-retroviral (ARVs) treatment for patients whose CD4 count falls below 350. But some are wondering whether the CDC should recommend starting ARVs at a CD4 count of 500, or perhaps soon after a person is tested positive – regardless of their CD4 count. Critics of those ideas worry that long-term toxicity issues are unknown, and whether patients will develop resistances at higher rates.
Dr. Rochelle Walensky, a Harvard University expert on cost effectiveness in health, said that clinical trials might pinpoint the true incremental benefits, and the benefits in further limiting transmission because of the early treatment. But she said that must be balanced against cost.
``If it takes three years to go from (a CD4 count) of 500 to 350, that’s $50,000 in drug costs right there,’’ she said. ``So we have dollars-per-person-in-life-year gained. Next question: Is it cost effective? Are resources limited? If so, what are we willing to pay for?’’
She raised a couple of comparisons: an estimated $5,000 to $10,000 to find each person newly infected with HIV; the costs of taking people off waking lists for ARVs; costs on treating hepatitis C, now one of the leading killers for people with full-blown AIDS.
``I don’t know the answer when to start treatment for HIV,’’ she said. ``But I think we should talk about what are the costs, and what are we going to get from it.’’
Friday, November 21, 2008
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