New York City to Offer Antiretroviral Treatment to All People with HIV

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New York City public health officials announced on World AIDS Day that they will begin offering antiretroviral therapy (ART) to all people diagnosed with HIV, regardless of CD4 T-cell count. The policy -- similar to one adopted by San Francisco in 2010 -- reflects a growing appreciation of the benefits of early treatment for both individual health and prevention of HIV transmission.

The latest U.S. federal antiretroviral treatment guidelines recommend starting therapy when a person's CD4 cell count falls below 500 cells/mm3. However, half of the panel that devises the recommendations favored starting above this level, and earlier treatment is advised for certain patient groups.

While the benefits of starting treatment when CD4 count falls below 350 cells/mm3 (the previous initiation threshold) are clear, there is mixed data about the benefits of starting above this level. Some experts believe it is important to suppress HIV as early as possible to reduce inflammation and other detrimental effects of persistent viral replication. Others, however, argue that we do not yet know enough about long-term toxicities, and controlled trials are still needed.

Antiretroviral therapy also plays a key role in prevention of HIV transmission. Data from the HPTN 052 study -- presented with much fanfare at the International AIDS Society meeting this summer in Rome -- showed that immediate ART reduced the risk of HIV transmission among serodiscordant couples by 96%. There is also growing evidence that lowering average "community viral load" can reduce HIV incidence on a population level.

This has raised concerns that individuals who do not yet need ART for the benefit of their own health may be pressured into starting treatment with unknown future consequences for the sake of public health.

The debate took off in the spring of 2010 when San Francisco announced its policy -- the first in the country -- of offering ART to anyone diagnosed with HIV. Compared with San Francisco, New York's public health system tends to care for people with more advanced disease, who have a lower CD4 cell count on average when diagnosed, so it is not yet clear how many people with CD4 counts above 500 cells/mm3 will be newly eligible for treatment.

"The New York City health department is a little bit ahead of the curve. In my opinion, the rest of the country will follow and I think it will be pretty quick," Michael Saag, past chair of the HIV Medicine Association (HIVMA), told the Associated Press.

"Nobody I know who is an HIV expert feels that it's a bad idea to treat HIV at high CD4 counts from a medical or scientific standpoint," concurred current HIVMA vice chair Joel Gallant said. "If there are objections, they'd usually be based on cost or feasibility."

"Providers should work with patients to prepare them for the long-term commitment to take medication daily, including addressing potential barriers to adherence prior to initiation," according to a Dear Colleague letter from New York City's Department of Health and Mental Hygiene. "When the decision to initiate treatment is made, ART should be prescribed and monitored by providers with experience in managing ART. Appropriate support should be made available to all who need it in order to maximize retention in care and treatment adherence to ensure successful treatment outcomes."

12/2/11

Sources

New York City Department of Health and Mental Hygiene. DOHMH now recommends offering antiretroviral treatment to any person living with HIV, regardless of the person’s CD4 cell count. Dear Colleague letter. December 1, 2011.

C Salazar. NYC Recommends AIDS Drugs For Any Person With HIV. Associated Press. December 1, 2011.