Northbay Uprising - Information for the liberated zones of the San Pablo Bay

2011-04-16 "SF's HIV policy could have huge impact, study says" by Erin Allday from "San Francisco Chronicle" newspaper
[http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/04/16/MN9G1J1NO1.DTL]
San Francisco's aggressive new policy recommending that everyone diagnosed with HIV start treatment immediately could dramatically cut the rate of new infections if it's widely accepted by patients and doctors, according to a study released Friday.
The infection rate among men who have sex with men could be lowered by more than 60 percent over the next eight years if everyone diagnosed with an HIV infection began taking antiviral drugs right away, instead of waiting for signs of a weakened immune system. And if the city instituted annual screening for all men who have sex with men on top of early drug treatment, rates of new infection could drop more than 80 percent, the study concluded.
The study, put together by researchers from UCSF and the San Francisco Department of Public Health, is based on a mathematical model, and it is impossible to say what the real-life effect of policy changes will be, public health officials said. It won't be known until later this year whether the recommendations, instituted last April, have increased the number of people starting antiviral drug treatment.
But AIDS experts who are proponents of early treatment with antiviral drugs - a controversial move that has not yet been embraced by federal public health leaders - said the study offers substantial weight to the ongoing debate.
"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 Edwin Charlebois, an associate professor at the UCSF Center for AIDS Prevention Studies and lead investigator of the study.
Federal guidelines -
Current federal guidelines, which are followed by most doctors and public health departments around the country, recommend that people infected with HIV begin antiviral treatment when their T-cell count, a measure of the strength of the immune system, falls below 500. San Francisco is one of the first cities to recommend that everyone who tests positive for HIV start antiviral therapy, regardless of the T-cell count.
But that's not an easy recommendation for patients and doctors to follow. Antiviral medications aren't without side effects, including possible kidney problems years down the line, and concerns remain about offering toxic drugs to people who are, aside from carrying the virus, healthy.
Antiviral drugs revolutionized treatment of HIV and AIDS when they became available in the mid-1990s, but they were potent, sometimes disabling medications. Partly for that reason, public health officials recommended early on that only HIV-positive individuals begin treatment only when they were symptomatic.
Since then, the drugs have become more efficient and much safer, doctors said and, slowly, federal guidelines have crept toward earlier treatment. Many doctors have done the same. In 2004, it took on average nearly three years from an HIV diagnosis for a patient in San Francisco to reach viral suppression - in 2008, that average had dropped to eight months after a positive test, according to data collected by the Public Health Department.
That suggests that many doctors started early treatment of HIV three or four years ago - even before the department made a policy change, said Dr. Moupali Das, its director of research in HIV prevention.
Virus is more toxic -
"There's a growing recognition that the virus is more toxic than the meds," said Das, one of the authors of the mathematical model study. "The meds are not without side effects, but they're so much improved."
How antiviral treatment reduces spread of the disease is still not entirely clear, although studies have shown that transmission rates between partners decrease when the infected person is being treated. The drugs decrease the amount of virus in the bloodstream, and one assumption among researchers is that there is also less virus in the genital tracts.
More precautions
In addition, people who are actively taking drugs are probably more aware of their disease, and therefore might be more likely to take precautions, such as using condoms, to prevent spread of the disease, said Dr. Michael Horberg, director of HIV/AIDS at Kaiser Permanente.
"There is a lot of evidence to support starting treatment earlier. We know that it will extend life. We know people whose viral loads are in control are less likely to spread the virus. And we know many of the complications from HIV disease are fewer in people whose viruses are well controlled," Horberg said. "Now the debate is how much earlier to start."
Das said that the model she helped put together is certainly encouraging, but she believes that public health and AIDS experts actually have everything they need now to eradicate transmission of HIV in San Francisco. "The interest and enthusiasm is there. It's all about the pragmatic implementation," she said.
Not so easy -
But that's a pretty tall order. Getting every HIV-infected man and woman onto antiviral drugs would be expensive, and that's just the cost of the medication. For the treatment to be effective, and to reduce drug resistance, it's critical that patients take their pills exactly as they're prescribed, and that's not always easy.
And while many doctors and public health experts say they would support a plan to institute regular annual screening for HIV - treating the blood tests the same as a pap smear or cholesterol check - there's no doubt that HIV remains a politicized and emotional topic.
"That's the real puzzle," said Dr. Grant Colfax, director of HIV prevention at San Francisco's Public Health Department. "How do you address the stigma and the discrimination, and provide the social support that's needed so people can have the choice about whether to get tested and start treatment?"