New Study Confirms Need for Early HIV Treatment

By Eric Brus

In late May, researchers in a major international study reported definitive evidence that early antiretroviral treatment (ART) substantially reduces HIV-infected persons' risks of developing AIDS or other serious illnesses. In particular, the study showed that people who start ART when their CD4 T-cell counts are relatively high (a key measure of immune system health) have better health outcomes than those who delay treatment until their CD4 cell counts drop to lower levels.

Together with data from earlier studies showing that ART reduces the risk of HIV transmission to uninfected sexual partners, this new information supports offering treatment to everyone infected with HIV.

The recent findings are from the Strategic Timing of AntiRetroviral Treatment (START) study, which began in 2011 and enrolled nearly 4,700 HIV-infected men and women in 35 countries with CD4 cell counts above 500. START's primary objective was to determine whether taking ART immediately would lower the risk of AIDS, other serious illnesses, or death compared to waiting until a person's CD4 cell count fell to 350 or lower.

"We now have clear-cut proof that it is of significantly greater health benefit to an HIV-infected person to start ART sooner rather than later," noted Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. "Moreover, early therapy conveys a double benefit, not only improving the health of individuals but at the same time, by lowering their viral load, reducing the risk they will transmit HIV to others. These findings have global implications for the treatment of HIV."

In a posting on the blog.AIDS.gov site, Fauci further noted that about 35 million people are currently living with HIV worldwide. In 2013 alone, an estimated 2.1 million persons were newly infected with the virus.

"Although the START trial now provides firm scientific proof of the benefits of early initiation of ART, to achieve full viral suppression for all HIV-infected individuals will require addressing a number of care and treatment challenges, including stable access to medications, access to trained health care workers, and achieving the high levels of adherence required for ART effectiveness," he said.

SC Upholds ACA Subsidies

In a much-anticipated decision, the U.S. Supreme Court ruled on June 25 that health care subsidies under the Patient Protection and Affordable Care Act (ACA) are legal. The 6-3 decision is a major victory for supporters of the ACA and health care reform. In the case known as King v. Burwell, opponents of the law challenged an Internal Revenue Service ruling that, under the ACA, individuals who purchase private health insurance through both federal and state-run health insurance exchanges are eligible for tax subsidies.

"This case had the potential to severely undermine and possibly implode the ACA," according to analysts at Harvard University's Center for Law and Health Policy Innovation (CLHPI). "If the challengers had prevailed, potentially five million Americans who recently gained coverage under the ACA would have lost their access to health insurance and health care, and the health insurance industries of 34 States would have been seriously harmed," CLHPI contends.

"Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," Chief Justice John Roberts wrote in the majority opinion. "The combination of no tax credits and an ineffective coverage requirement could well push a state's individual insurance market into a death spiral. It is implausible that Congress meant the Act to operate in this manner."

Judge Antonin Scalia sharply disagreed with the Court's majority in his dissenting opinion, joined by justices Alito and Thomas. He called the majority's interpretation of ACA's subsidy language "quite absurd" and argued that "words no longer have meaning if an Exchange that is not established by the State is 'established by the State.'"

The decision was widely hailed by proponents of health care reform, including the American Public Health Association (APHA). "We are pleased the Court understood the legislative history and intent of this law and ruled in favor of the [Obama] Administration," according to an APHA statement. "This ruling ensures that health insurance tax credits will remain available in all states and more importantly that health insurance will remain affordable for those people who receive it through the exchanges."

Scott Schoettes, HIV project director for Lambda Legal, agreed.

"The majority ruled to preserve the tax credits and maintain the integrity of the ACA, protecting access for all, including people living with HIV who are low-income, rural, southern, black, and were -- before the ACA -- largely uninsured," Schoettes noted. "No one should be put at greater risk to the ravages of HIV simply because they live in one of the 34 states choosing not to set up its own health insurance exchange."

HIV Outbreak in Rural Indiana

The number of newly reported cases of HIV in rural Scott County in southeastern Indiana has slowed during the past two months, rising from 153 in mid-May to 174 by July 14. Officials from the Indiana State Department of Health (ISDH) are continuing to work with local health departments, health care providers, and others to contain the spread of HIV. Disease intervention specialists are interviewing each newly identified HIV-infected person to obtain information about needle-sharing and sex partners, as well as helping persons connect to care coordination services, medical care, and HIV prevention information.

Eighty-six percent of the HIV-positive persons in the recent outbreak are coinfected with hepatitis C virus (HCV), ISDH officials reported at a mid-June briefing. At that time, 69 percent were engaged in care and seven percent were virally suppressed. Indiana health officials identified two main goals in their continuing response to the outbreak: "1) suppress and sustain suppression of the community viral load; and 2) provide all services vital and necessary to identify and care for HIV-positive individuals and high-risk negatives with the Local Health Department Needle Exchange Program through coordination and collaboration at a local level."

Eric Brus is the Director of Health Information at AIDS Action Committee. This report is produced by the Health Library of the AIDS Action Committee in collaboration with the New England AIDS Education and Training Center Minority AIDS Initiative Project. The full version is available online.