New HIV Treatment Guidelines & Other Updates
The new guidelines recommend that all HIV positive Americans start Antiretroviral (ARV) therapy soon after diagnosis. Previously, ARVs were recommended for People Living with HIV (PLWH) whose CD4 counts fell below 500.
While the ultimate decision about when to start treatment remains in the hands of the individual and his or her doctor, the new guidelines make the panel's recommendation about when to start treatment very clear. No longer are we dependent on CD4 counts that can fluctuate. In some ways, it may eliminate HIV-related health disparities and may result in more health care professionals feeling confident about their ability to treat PLWH.
The new guidelines did not wait for the results of the Strategies for Management of Anti-Retroviral Therapy (SMART) study. This study was supposed to determine the best time to start therapy. Treatment as Prevention (TasP) is an essential component of our efforts to end the HIV/AIDS epidemic; however, without the science of the SMART study, I am concerned that the guidelines were changed because of the excitement around TasP's potential without waiting for the results from this study.
While it's not the function of the panel, I am also concerned about our ability to pay for treatment.
According to the Centers for Disease Control and Prevention (CDC), there are around 1.2 million Americans living with HIV, just over 941,000 of them are aware of their status. Currently just over 328,000 HIV positive Americans have an undetectable viral load. If we follow the new guidelines and just use the PLWH already identified, approximately 613,000 individuals will need to start/reassess their ARV therapy. Some of them are already on treatment, but have not achieved viral suppression because they are on suboptimal treatment. The medications alone could cost as much as $8,500,000,000 per year
Until the Patient Protection and Affordable Care Act is fully implemented, enrolling this many new individuals onto treatment poses significant challenges. Most people who have private insurance or are enrolled in Medicaid or Medicare will get these life extending drugs. Still, others will be able to take advantage of the Pre-existing Condition Insurance Programs set up under the ACA to help individuals with chronic conditions receive care before all of the law’s provisions are implemented. However, many people who fall between these programs will need to rely on the AIDS Drug Assistance Program (ADAP). We still have a waiting list for this program and we don't know how many PLWHs were dropped from state's ADAP programs due to changes in eligibility.
While ADAP funding has increased steadily each year, support for the rest of the Ryan White Care Act (RWCA) remains relatively flat, with Part D receiving a significant cut in President Obama's 2013 budget request. Many communities do not have the capacity to expand services for an additional 613,000 consumers without significant increases in funding. Yet during these tough economic times, Congress does not seem willing to appropriate the resources necessary to cover this many new PLWH seeking ARVs even though treatment is recommended by the new guidelines.
From the beginning, the National Minority AIDS Council (NMAC) has said it would be impossible to implement TasP without the full implementation of the Patient Protection and Affordable Care Act. Our current system is at a breaking point. It cannot absorb an additional 613,000 HIV-positive Americans without additional resources.
My nightmare scenario is that the results of the SMART study show a different starting point to begin therapy. More likely, we enroll many more people onto ARVs, only to find out we don't have the funds to pay for the drugs. As a result, healthcare providers may still need to counsel PLWH on starting treatment only when they have consistent access and can remain adherent causing unnecessary stress and worry within communities that are already stressed and worried. Can you imagine means testing for the ADAP program? While we need treatment on demand for PLWH, we recommend caution as communities move forward to implement these new treatment guidelines.
Yours in the struggle,
Today, NMAC is an association of AIDS service organizations providing valuable information to community-based organizations, hospitals, clinics and other groups assisting individuals and families affected by the AIDS epidemic. NMAC's advocacy efforts are funded through private funders and donors only.
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