City health officials said Thursday they are recommending that any person living with HIV be offered AIDS drugs as soon as they are diagnosed with the virus, an aggressive move that has been shown to prolong life and stem the spread of the disease.
Standard practice has been to have patients put off the expensive pill regimen — which can cost up to $15,000 a year in the United States — until the immune system weakens.
But New York City Health Commissioner Thomas Farley said recent studies have shown that the benefits of early treatment, combined with education and testing, appear to be a promising strategy for countering the epidemic.
"I'm more optimistic now than I've ever been about this epidemic that we can drive our new rates down to zero or close to it — eventually. I don't know how soon. But I'm very optimistic of the direction that it's going to take the epidemic to," Farley said in an interview Wednesday.
More than 110,000 people in New York City are infected with HIV, more than in any other U.S. city and about 75 percent of all cases in the state. San Francisco, which had more than 18,000 people living with HIV, is believed to be the only other major city to have made a similar recommendation in 2010.
City health officials said the new recommendation could initially help about 3,000 people get on medications. About 66,000 New Yorkers living with HIV that the Health Department tracks are being effectively treated with AIDS drugs, they said. But they said it was difficult to estimate how many people would eventually need the medications.
Some doctors agree with the Department of Health that it is time to update the guidelines for initiating AIDS drug 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," said Dr. Michael Saag of the University of Alabama at Birmingham and past chairman of the HIV Medicine Association.
The standard measure of the CD4 count — a way to measure the strength of the immune system — is an outdated trigger for therapy, a relic from research on early antiretroviral drugs, Saag said.
"It's an anachronism. It's old school. It's yesterday," Saag said. "I agree completely with the New York City health department."
Dr. Joel Gallant of Johns Hopkins University School of Medicine and vice chair of the HIV Medicine Association also agrees with the New York recommendation for offering early treatment. He recommends early treatment for his own patients.
"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," Gallant said. "If there are objections, they'd usually be based on cost or feasibility."
Saag said the cost questions are very important because brand-name drugs can retail for $1,200 to $1,600 per month.
"For sure, they're very expensive drugs and we should be careful about that," he said, though he added that the medications are going generic so costs should come down.
City health officials said they anticipated that the cost for expanding the use of AIDS drugs would be covered by private insurance or by the AIDS Drug Assistance Program, a $270 million program for the uninsured or underinsured that is partially funded through federal dollars. The health officials said they expect the benefits over the long term would far outweigh the initial costs because there would be fewer hospitalizations and new HIV cases.
"There will be some increasing costs over the short term," said Farley. "But over the long term, it's absolutely the right thing for the epidemic."
HIV experts are split about whether early therapy should be recommended or optional. Besides the high costs, the pills have side effects from nausea to liver damage. Patients unwilling to take them religiously for life could develop drug resistance.
A panel that recently updated U.S. guidelines was divided evenly, with half favoring starting therapy early for everyone and half regarding an early start as elective.
But there's growing evidence that untreated HIV can lead to cancers and heart disease. What's more, antiretroviral drugs are safer, have fewer side effects and work better than they did in the past. New research also indicates that people live better, healthier lives and their sex partners are less likely to get infected.
The new research cited by the city's Health Department in making its recommendations includes a nine-nation study whose preliminary results were announced earlier this year and showed that earlier treatment meant patients were 96 percent less likely to spread the virus to their uninfected partners.
Dr. Moupali Das, the director of research at the San Francisco Department of Health HIV Prevention Section, said its surveillance data indicated that physicians were treating their HIV patients early even before the city recommended doing so. She said the average amount of time from diagnosis to having no virus in the blood went from 32 months in 2004 to eight months in 2008.
"That reflects that the newer medications are more potent and efficacious, and the doctors were likely initiating them earlier," she said.
She said they are currently analyzing what has happened since the recommendations went into effect. But, anecdotally, she said that there has been a change among patients seeking treatment. "It's changed the dialogue and empowered our patient population," she said.
Public health experts predict the guidelines for starting AIDS drugs treatment will shift toward a clear recommendation for early treatment.
But New York City's health commissioner said officials there could not wait to respond.
"What we're doing here is we're making a really clear and unequivocal statement that we think this is good for the health of the patient, good for the health of the entire population, good for the response to the epidemic," Farley said.