FUTURE PERSPECTIVES

The involvement of uPA/uPAR in trapping HIV virions within the cell has drug target potential.

Also, as suPAR is a strong marker of HIV disease progression, the addition of suPAR to other markers of progression such as CD4 T cell counts and HIV viral load may be relevant.

This should be determined in a randomised study where the decision making on when to initiate HAART is based on suPAR and CD4 count. The hypothesis would be that individuals with high suPAR should initiate HAART at higher CD4 count according to (Fig. 4).

Figure 4: Algorithm of suPAR and CD4 count guided initiation of ART.

Current recommendations on when to start antiretroviral therapy (ART) were discussed by an expert panel at the International AIDS conference in Mexico 2008 and the conclusions were, in agreement with WHO guidelines:

1. Start therapy in any patient with symptomatic HIV disease, regardless of CD4 count or viral load, and asymptomatic patients with less than 200∕μL CD4 cell count.

2. Initiation of therapy in patients within the 200 to 350∕μL CD4 cell count range should be strongly considered and individualized.

Hence, in the CD4 window between 350 and 200 cells per μl, the measurement of suPAR can be used to guide clinical decision making. If the hypothesis is proven through a randomised study, that is if knowledge of the inflammatory state of the HIV positive patient gives the clinician better grounds for deciding when to initiate ART and whether the patients is responding to the treatment regime, the use of suPAR and CD4 count could enhance treatment efficacy in particular in areas of the world where measurement of viral load is currently unavailable due to cost and technical demands.