San Francisco: Earlier HAART Treatment Appears To Reduce New HIV Infections

According to a story posted on AIDSmap.com, San Francisco is seeing a decrease in new HIV infections because HIV+ people are going on medication sooner and therefore have a reduced period of infectiousness.

Dr Das presented more evidence from San Francisco to show a strong correlation between reductions in community viral load and the falling number of HIV diagnoses. The most recent CVL, defined as the average viral load of all HIV positive people being seen for care in the city, went down from approximately 25,000 copies/ml in 2004 to 10,000 copies/ml in 2009. Over the same time, new diagnoses of HIV decreased from 820 in 2004 to 500 in 2009. For CVL to decrease, a number of other things have to happen first, in a ‘cascade’ of events. Firstly, the frequency of testing in the at-risk population must increase; this must result in a lower proportion of undiagnosed cases; those diagnosed must be linked to care, and the majority must start treatment; and the time between diagnosis and viral suppression must reduce. Dr Das said all these indicators were strongly correlated. The average time from diagnosis to the start of treatment shrank from twelve months in 2004 to two months in 2009. The time between diagnosis and achieving an undetectable viral load went down from nearly three years in 2004 to eight months in 2009; and the percentage with an undetectable viral load within a year of diagnosis increased from 26% in 2004 to 82% in 2008.

Last April the San Francisco Department of Public Health adopted the controversial position that newly infected patients should immediately begin HAART therapy upon their diagnosis. Some AIDS activists strongly objected to that, citing the prevailing opinion that HAART treatment should be delayed as long as possible due to the long-term side effects of the medications. Many HIV specialists continue to recommend a closely-monitored delay in treatment, but the above result in San Francisco should not be discounted.

(Tipped by JMG reader Bill)

CDC Issues Interim PrEP Guidance

Last last year researchers announced some success in preventing HIV among gay men who were taking a daily dose of the HIV medication Truvada. The concept of warding off infection by pre-dosing with a medication is known as pre-exposure prophylaxis (PrEP.) But alarmed by the prospect for abuse, yesterday the CDC issued some interim PReP guidance as studies continue.

CDC says it wanted to fend off improper use of pre-exposure prophylaxis (or, more catchily, PrEP) as it and other agencies work on more detailed guidelines, which will take “several months.” It says that the drug should only be used in men who have sex with men, since studies in other high-risk groups such as IV drug users are still underway. And it should be used only in high-risk men (with multiple partners or partners from an area with a high prevalence of HIV infection), who are most likely to benefit. Also, the drug isn’t the equivalent of the morning-after pill for HIV; it’s meant to be taken daily. “Support for adherence to the prescribed medication regimen must be a routine component” of PrEP, the CDC says. (In the study, the risk of HIV infection was reduced just 21% in men whose adherence was less than 90%, compared to a 73% lower risk of infection for those with adherence of 90% or better.) And other preventive measures, such as condom use, should continue to be taken.

The wholesale cost of Truvada in the United States is $1000 for a month's supply, a cost unlikely to be covered by insurance when the drug is used as a preventive. In some countries, Truvada costs as little as $12/month.