A major international clinical trial has provided the strongest evidence yet that people infected with H.I.V., the virus that causes AIDS, should get treated as soon as possible, even if they are feeling well, to ward off serious illness and fatal complications in future years. The finding raises the powerful moral question of whether global and national organizations can find the will — and the resources — to protect millions of people from deaths and diseases that could be prevented.
The study was conducted in 35 countries and designed to end the debate about when to start treatment. The randomized trial enrolled 4,685 men and women who were infected with H.I.V. and whose CD4 cell counts, a measure of immune system strength, were still normal. About half of them were started on treatment with antiretroviral drugs immediately. The other half were given treatment only after their counts fell to a worrisome level.
The results were striking. After being followed for an average of three years, those in the immediate-treatment group were 53 percent less likely to die or develop AIDS or other serious illnesses than those in the deferred-treatment group. There were 86 such events among those with deferred treatment but only 41 in the early-treatment group.
Based on these results and previous studies that were smaller or more limited, the National Institute of Allergy and Infectious Diseases, the primary funder of the study, recommended offering treatment to everyone infected with H.I.V. Currently, fewer than 14 million of the estimated 35 million people in the world infected with H.I.V. are taking antiretroviral drugs. Treating all the infected people in the world’s poor and middle-income countries immediately would cost almost $20 billion, roughly triple the current expenditures.
While costly, putting all H.I.V.-infected people on the drug regimen would provide a double benefit. It would improve the health of those infected and, by suppressing the amount of virus in their bodies, lessen the risk that they might spread the virus to others, through unprotected sex or through needle-sharing among drug addicts.
In the United States, current guidelines recommend that all H.I.V.-infected people take antiretrovirals regardless of their CD4 counts. San Francisco has been recommending immediate treatment since 2010, and new infections in that city have dropped substantially since then. New York City has been urging immediate treatment since 2011 but has not yet seen the same sharp decline in new cases. Nationally, only about 450,000 of the estimated 1.2 million people infected with H.I.V. are undergoing treatment.
A committee of the World Health Organization is planning to issue new treatment guidelines soon. It has good reason to recommend treatment for all infected people, even those with normal CD4 counts.