A new paradigm for HIV treatment in New York?

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New York City s health commissioner Dr. Thomas Farley is pushing for a change in city health policy on HIV: He recommends that doctors start patients on treatment as soon as they are diagnosed. By making early treatment a standard policy, Dr. Farley hopes to reduce transmission and dramatically lower or even eradicate the city s burden of HIV.

The most significant research cited by the city s Health Department are the much-celebrated results of a study conducted in nine African countries: Researchers announced earlier this year that starting patients on anti-retroviral drugs upon diagnosis of HIV reduced transmission of the virus to their partners by 96 percent. The new policy follows the lead of one adopted in 2010 by San Francisco health officials, where doctors had begun administering early treatment even before these city guidelines went into effect. While it is still too early for any significant data to have been gathered, anecdotal evidence suggests that, so far, HIV patients in San Francisco have reacted positively to the city s new policy. The guidelines that New York and San Francisco adopt are important, since other cities are likely to follow their example.

ACSH s Dr. Josh Bloom notes that implementation of the new policy means balancing the needs of infected individuals with those of the community. He says, earlier intervention with antiretroviral drugs would certainly reduce transmission rates, but it s not yet known what the impact on the infected patients themselves would be. Currently, HIV patients often begin treatment when their T-cell counts a measure of immune system function fall below a certain count, but this too has been a controversial paradigm.

Cost is also an issue. City health officials estimate that the cost of expanding the use of AIDS drugs will eventually be outweighed by the long-term benefits, such as fewer new HIV cases and hospitalizations. Yet while health officials stated that the federally funded AIDS Drug Assistance Program would absorb the cost of early treatment for the uninsured or underinsured, others have suggested that the situation is not quite so neat.

Charles King, the president of Housing Works, an advocacy group for New Yorkers with HIV and AIDS, pointed out that impoverished people with HIV often delay treatment until the disease has progressed to AIDS, at which point the severity of their illness qualifies them for city housing and nutritional benefits. Were they to begin treatment early, they d effectively forfeit these benefits. ACSH s Leah Wibecan wonders whether the city s new treatment guidelines will bring to light the counterproductive aspects of the current policy. Dr. Bloom adds, Any policy that, in effect, rewards people for intentionally getting sicker is patently insane.

Currently, more than 110,000 New Yorkers are living with HIV the highest number in any U.S. city. While a federal panel that recently updated the country s guidelines was split on the question of early treatment, there is no doubt that the eventual impact of New York City s new policy will serve as an object lesson for cities around the world.