October 22, 2012
As has often been the case in the history of the HIV epidemic, the HIV/AIDS Division at San Francisco General Hospital and the San Francisco Department of Health were ahead of the curve in 2010 when they issued a recommendation that all people with HIV should receive treatment, regardless of CD4 count. Of course, U.S. guidelines (first DHHS, now IAS-USA) followed suit -- but how did the San Francisco experience play out?
In a paper just published in Clinical Infectious Diseases, Elvin Geng and colleagues describe temporal trends in HIV RNA among 2245 patients receiving care at a publicly funded clinic at San Francisco General Hospital between 2001 and 2011. The patients were predominantly male (87%) and white (54%), and 21% had a history of injection drug use.
During the study period, the proportion with virologic suppression in the cohort more than doubled, from 34% in 2001 to 72% in 2011. But the truly striking change occurred among the 534 patients who entered care with CD4 counts > 500 -- here, the proportion increased more than 5-fold, from only 10% up to 53%, with the sharpest increase taking place after the 2010 policy change. Indeed, among patients with CD4 counts > 500, those who entered care in 2010-11 were 6.5 times more likely to attain an undetectable viral load than those who entered care in 2007-2009. More good news: The risk of virologic rebound was lowest for patients who started treatment with the highest CD4 counts.
Data on insurance status, homelessness, and psychiatric disease were not provided, but based on prior reports from this clinic, I would assume this was a challenging patient population -- making the results all the more impressive.
I emailed Brad Hare, one of the co-authors on the paper and director of the clinic, and he provided some interesting insights and some follow-up. He said that having this "treat all" policy enabled the clinicians -- especially the NPs, who do a substantial proportion of the primary care -- to feel more justified in recommending treatment for asymptomatic patients, even if they had believed treatment was beneficial before the policy. (I'm sure the publication of HPTN 052 didn't hurt either.)
And the most recent data from their clinic? Antiretroviral therapy was recommended to 92% of newly diagnosed patients, with 83% virologically suppressed.
Of course, it's hard to know if this San Francisco experience is generalizable, given that many things in that city are, ahem, distinctive. But if I were planning at "test and treat" program somewhere in the world, and someone questioned the feasibility, this is definitely the first paper I'd cite in defense of moving forward.
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.