San Francisco Endorses New Policy for Treatment of HIV

Under new guidelines, San Francisco public health officials will now advise newly diagnosed HIV patients to begin antiretroviral therapy at once, rather than waiting to start ARVs when their immune system falters. The city Department of Public Health (SFDPH) policy is a response to increasing evidence that HIV patients treated earlier in the course of infection live longer and suffer fewer illnesses than those who start later.

In patients with long-term HIV infection, the effects of chronic inflammation may have already taken a toll by the time they begin ARV treatment, say experts. In a study published last year in the New England Journal of Medicine, US patients who started treatment later had a two-fold greater risk of dying from any cause than those who began therapy when their T-cell counts were still above 500.

Earlier treatment may have the added benefit of slashing viral loads in the population, thereby reducing the risk of onward transmission.

Katz said the benefits of earlier treatment would outweigh its expenses. California's Office of AIDS is working with CDC to estimate the cost of earlier treatment; factors affecting cost include participation rate, patients' T-cell counts, and whether they are privately insured.

"The field is moving, inexorably, to earlier and earlier therapy," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

Nonetheless, HIV experts recently convened by the Department of Health and Human Services were split on whether to start ARVs in HIV patients whose T-cell counts are above 500. Rigorous, randomized clinical trials should guide the decision, as no one knows the effects of taking ARVs for decades, said some experts. A University of Minnesota study about the issue should yield results by 2015.

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