A New England Journal of Medicine article published Thursday, April 30, “Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival,” provides the best evidence yet that starting treatment for people with HIV early on improves health outcomes. While many have suspected this was the case, this study is the first that looks at the difference in outcomes for people who initiate treatment when their T-cell count is above 500. The study highlights the troubling fact that New York City and State continue to cling to an antiquated definition of HIV-related illness and an approach to HIV that has tragic consequences.
The study found that people who begin antiretroviral AIDS treatments before their CD4 cells go below 500 have significantly better health outcomes. In fact, the critical finding is that people who wait until their T-cell count falls below 500 have a 94% increased rate of mortality over folks who initiate treatment earlier. Those who wait until their T-cells fall below 350 have a similarly dramatic increased risk of mortality.
Yet here in New York State, the general standard of care, as promulgated by the New York State AIDS Institute, does not recommend universal offering of treatment until T-cells have fallen below 350. Not only that, but the AIDS Institute definition of “HIV-related illness,” which determines access to HIV housing assistance state-wide and almost all HIV/AIDS services in New York City, remains a T-cell count below 200. The AIDS Institute announced recently that it is reviewing treatment guidelines in light of this study but said nothing about the definition of HIV-related illness.
A horrible choice
Research also shows a strong and consistent relationship between housing status and HIV treatment access, health, and risk behaviors, regardless of personal characteristics and service use, and that housing assistance is among the strongest predictor of health outcomes. Housing Works has strongly advocated making HIV/AIDS services, including housing assistance, available to all low-income people living with HIV, something both New York City’s mayor and city council speaker have opposed. But it would be criminal for the AIDS Institute to change its treatment guidelines without changing the definition of HIV-related illness.
Already, low income New Yorkers are put in the position of having to make the horrible choice between initiating treatment that can dramatically prolong their lives but preclude them from receiving equally life-saving housing and services or waiting until their HIV illness advances to the point that they qualify for help while hoping that their immune system can recover, something it never fully accomplishes. Recommendations regarding early treatment would make this choice even more pernicious.
The evidence is very clear. Housing and services are as critical to care for people with HIV as medication. Not only that, but housing and services are a cost-effective way to prevent transmission. We should not make people living with HIV decide whether to risk their lives by remaining homeless or by refusing treatment. The AIDS Institute must act now to change both the treatment guidelines to mandate that people who are infected be universally offered treatment on a voluntary basis and to change the definition of “HIV illness” to HIV infection.
A version of the above was published as an op-ed in the May 28, 2009 issue of Gay City News.
Posted on May 29, 2009 at 12:18 am