San Francisco policy may cut HIV for gay men by 60 percent
San Francisco's policy of recommending HIV treatment to all infected patients upon diagnosis, without waiting for CD4 cell counts to fall, could cut the number of new infections among men who have sex with men by 59 percent in five years, a new study suggests. In addition, combining early treatment with annual testing for all MSM would reduce new infections among them by 76 percent.
When to initiate antiretroviral therapy has long been debated. Early HIV medications carried the risk of such severe side effects that public health officials recommended patients not begin treatment until they were symptomatic. The drugs have since improved, and studies have shown more favorable outcomes under earlier ART initiation. Last year, San Francisco Department of Public Health (DPH) recommended treatment for all HIV patients as soon as they are diagnosed.
"There's a growing recognition that the virus is more toxic than the meds," said study co-author Dr. Moupali Das, DPH's HIV prevention research director. "The meds are not without side effects, but they're so much improved." DPH developed the study's mathematical model with the University of California-San Francisco (UCSF).
"We could have a really significant impact on the number of new cases by taking everyone with a diagnosis and encouraging them to start treatment. And those effects could actually begin quite quickly," said study leader Edwin Charlebois of UCSF.
Three scenarios were tested: ART initiated when CD4 counts fall below 500 (the current U.S. standard of care); offering treatment to all HIV patients currently in care; and intensified annual HIV testing for MSM, with treatment offered to all.
"In conclusion, our projections suggest that ensuring HIV-infected patients in San Francisco already receiving care are offered ART would significantly reduce the incidence of HIV infection in San Francisco. These predictions are supported by recent surveillance data from San Francisco and Vancouver that show decreasing rates of new HIV infections that correlate with ART expansion and lower community viral load. With new national guidelines supporting treatment for most HIV-infected persons for their individual health, secondary benefits of reducing HIV transmission could be realized if adequate support for care delivery are in place."
The full study, "The Effect of Expanded Antiretroviral Treatment Strategies on the HIV Epidemic Among Men Who Have Sex With Men in San Francisco," was published in Clinical Infectious Diseases (2011;52(8):1046-1049).