US doctors seem to be very willing to start drugs earlier in disease, while their EU colleagues are slower and more conservative. Recent examples: the ever-wider indication for statins, the disproportionate uptake of drugs for attention-deficit / hyperactivity and opioids for pain relief. The new US HIV treatment guidelines are following this same trend.
The April 2014 HIV Guidelines[1] recommend that all HIV infected patients receive treatment regardless of CD4 count. While there is fairly solid data for situations when the CD4 count is < 350, it becomes less convincing for patients with CD4 counts above this cut-off. Indeed, when the CD4 counts are > 500 this is admittedly a “B” recommendation i.e., only a ‘moderately strong’ endorsement. What is bothering is the fact that it is actually a “B III” recommendation which is not based on data but reflects expert opinion. The reason given by the Advisory Panel is to ‘reduce the risk of disease progression’. Their EU counterparts beg to differ.
The European AIDS Clinical Society (EACS) Guideline[2] from Oct. 2013 takes a more nuanced approach. For patients with asymptomatic HIV infection, treatment is a ‘consideration’. The risk of drug side effects is mentioned by the experts who feel that the risk / benefit ratio is unclear. Even the risk of cardiovascular disease with long-standing HIV infection (an argument for early treatment by US guideline authors) does not sway these experts: ART is a ‘consideration’, not a recommendation in this population as well.
It does not come as a surprise when recommendations diverge that have no basis in fact. In a 2010 article, Khan (Clin Inf Dis 2010; 51:1147) reported an analysis of IDSA guidelines. A stunning 55% of ‘recommendations’ were solely based on expert opinions, not controlled trial information. Clearly, a lot of guideline ink is spilled on expert belief systems.
In this age of evidence-based medicine, why even have “B III” opinion pieces in a Guidance? For the newly diagnosed HIV patient the decision when to start and commit to ART for the rest of his life is monumental. Without demonstration of benefit, there is no justification in pushing drugs.
[1] http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf
[2] http://www.eacsociety.org/Portals/0/Guidelines_Online_131014.pdf
