Fighting H.I.V., a Community at a Time

Fighting H.I.V., a Community at a Time
By SUSAN OKIE
Copyright by The New York Times
Published: October 26, 2009
http://www.nytimes.com/2009/10/27/health/27hiv.html?hpw


WASHINGTON — Federal health officials are preparing a plan to study a bold new strategy to stop the spread of the AIDS virus: routinely testing virtually every adult in a community, and promptly treating those found to be infected.

The strategy is called “test and treat,” and officials say the two sites for the three-year study will be the District of Columbia and the Bronx — locales with some of the nation’s highest rates of infection with human immunodeficiency virus.

The officials emphasize that this is just a first step. The goal is not to measure whether “test and treat” actually works to slow an epidemic, but whether such a strategy can even be carried out, given the many barriers to being tested and getting medical care.

On the path from infection to treatment, “we lose people at every single step,” said Dr. Shannon L. Hader, director of the H.I.V./AIDS administration at this city’s Department of Health.

As many as 5 percent of the adults in the District of Columbia are infected — a rate Dr. Hader says is comparable with those in West Africa — and one-third to one-half do not even know they harbor the virus. (Nationwide, 20 percent to 25 percent of people who are H.I.V. positive do not know of their infections, according to the federal Centers for Disease Control and Prevention.)

And even when infection is diagnosed, “getting people from the field to the doctor is the hardest component,” said Angela Fulwood Wood, deputy director of Family and Medical Counseling Service, an agency that operates a mobile H.I.V. testing clinic here. Often, she added, someone who has just tested positive “can walk off that day and decide, ‘I’m going to pretend that never happened.’ ”

In 2006, only about half of Washington residents who had a new diagnosis of H.I.V. saw a doctor about the problem within six months.

The C.D.C. recommends routine, voluntary H.I.V. testing for everyone ages 13 to 64 as a part of regular medical care. But experts say the recommendation is not being followed in many hospitals, clinics and medical practices.

Even when doctors do offer the test to patients, “a significant number refuse,” said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, which is to pay for the test and treat feasibility study.

Researchers planning the study have been meeting with hospital and health officials in Washington and the Bronx to discuss making H.I.V. testing a routine part of visits to doctors, clinics and emergency rooms.

Dr. Fauci said testing might also be widely offered in nonmedical settings. “When you have a campaign like this, you’ve got to pull out all the stops,” he said. “How are we going to get everybody? Should we have testing in Wal-Mart? Should we have testing at Nathan’s hot dog places?”

The test and treat approach is part of a broader shift toward using medicines for H.I.V. to prevent infection. When an infected person starts taking one of the standard three-drug regimens, the level of the virus in blood and other body fluids drops rapidly, often to undetectable levels.

Doctors in developed countries now routinely test all pregnant women for H.I.V. because treatment prevents an infected woman from transmitting the virus to her fetus. In July, researchers conducting a large randomized trial in Malawi reported that giving the antiretroviral drug nevirapine to breast-feeding infants of infected mothers, or giving the mothers a three-drug regimen, protected the babies from infection through breast milk.

Studies tracking heterosexual couples in which one person is infected have found that after highly effective drugs for H.I.V. became available, uninfected partners were far less likely to contract the virus. Trials are under way to give H.I.V. drugs as a protective measure to uninfected people at high risk.

Current treatment guidelines do not call for antiretroviral drugs until there is evidence of progressive damage to the immune system — generally, until the number of CD4 cells, the white blood cells attacked by the virus, drops to 350 per milliliter or lower. (A normal count is at least 1,000.)

The guidelines are intended to balance the treatment benefits with the side effects from the drugs and the possibility of fostering drug resistance in the virus. But there is mounting evidence that early treatment keeps infected people healthy longer.

And that could have much wider benefits, researchers say. Last January, Dr. Reuben Granich and colleagues at the World Health Organization published a provocative study using mathematical models to predict the effects of universal testing and immediate treatment on a severe H.I.V. epidemic among heterosexuals. They reported that such a policy, if combined with prevention efforts like promotion of condoms and male circumcision, could virtually eliminate transmission of the virus within 10 years.

So far, despite some ambitious efforts, no city or country has come close to achieving universal testing for H.I.V. and treatment for all those infected. But researchers and public health officials are eager to test the potential of such a strategy for stemming the epidemic.

Among specialists, there is already a move toward starting treatment earlier, said Dr. Raymond Martins, chief medical officer of Whitman-Walker Clinic, the largest provider of H.I.V. care in the District of Columbia.

But in low-income neighborhoods in Washington, some people are reluctant to start treatment, said Ms. Wood, whose H.I.V. testing program and clinic are based in Anacostia, a community in Southeast Washington that has long had high rates of drug abuse and H.I.V. infection, as well as a shortage of health services. Early H.I.V. drugs had multiple side effects, including fat deposits on the upper back that created an unsightly hump. “People saw that when others started taking the medicine, they seemed to get worse,” Ms. Wood recalled.

Although the latest drugs have far fewer side effects, many patients still fear that “going on the medicines means I’m starting to get sick,” she added. A critical component of test and treat will be conveying the message: “Don’t wait until you’re sick. Do it early.”

In the District of Columbia, heterosexual sex is the most common mode of transmission reported by patients with newly diagnosed H.I.V. Researchers say that makes the city a strong candidate for test and treat, because the strategy is likely to be more effective in preventing spread among heterosexuals than among drug abusers or men who have sex with men.

In New York City, the Bronx has the highest AIDS death rate of any borough, even though Manhattan has a higher rate of cases. Dr. Monica Sweeney, the city’s assistant health commissioner for H.I.V. prevention and control, said that was because people in the Bronx tended to wait longer to be tested and get a diagnosis.

In the first half of 2008, Dr. Sweeney said, “more than a quarter of the people who were tested in the Bronx had AIDS by the time they received their diagnosis.” By contrast, she added, people who are tested and treated before the immune system has suffered extensive damage “can expect almost a normal life expectancy.”

Health officials in both Washington and the Bronx are already in the middle of campaigns to promote H.I.V. testing and increase the number of new patients who get prompt medical care. In the first year of a program called Bronx Knows, begun in mid-2008, 70 percent of residents with a confirmed positive H.I.V. test were sent to doctors and clinics for care, Dr. Sweeney said.

In the District of Columbia in 2006, only 50 percent of those with new diagnoses of H.I.V. saw a doctor for the problem within six months. Community outreach workers who perform testing are now being retrained to focus on getting their clients into treatment.

“If you’re doing H.I.V. testing, your job doesn’t end with just telling the individual their test results,” said Dr. Hader, of the district’s Health Department.

At a neighborhood fair a few weeks ago in Oxon Run Park in the southernmost corner of Washington, a worker passed a basket of condoms among the crowd waiting in line for hamburgers, while announcements over a loudspeaker urged attendees to visit Family and Medical Counseling Service’s mobile H.I.V. testing unit, inside a brightly painted trailer parked under the trees.

Annie Samuel, a 40-year-old mother of four, smiling and youthful-looking in shorts and a yellow tank top, knocked on the trailer’s door. “I’ve got to get tested,” Ms. Samuel said. “I want to be around to see my kids and grandkids.”

Beverly Honesty, an outreach worker, seated Ms. Samuel at a table and asked her to sign some forms, then had her swab her gums with a white plastic stick tipped with filter paper to get a sample of cells lining her mouth.

Next, Ms. Honesty inserted the stick into a tube containing a clear solution, part of a rapid test kit that detects H.I.V. antibodies, chemicals made by the immune system that indicate infection with the virus. As they waited for the result, Ms. Honesty quizzed Ms. Samuel about high-risk behaviors and talked to her about unprotected sex, contaminated needles in tattoo parlors and other possible ways of contracting H.I.V. After 20 minutes, she showed Ms. Samuel her result: negative.

Positive results obtained with the kits are reported to the Health Department but are considered preliminary, and must be confirmed by a different test that requires a blood sample.

“There are so many people who test ‘preliminary reactive’ who never return,” said Torena White, who was leading the outreach team that afternoon.

Often, testers following up on such results must repeatedly call clients or send them letters. If someone with a positive test still does not respond, a Health Department worker is dispatched to try to track the person down.

Community testing programs are likely to attract people who suspect that they might have contracted H.I.V. But Ms. Wood said the key to test and treat would be capturing those who did not volunteer for testing because they did not believe they could be infected —“people who are promiscuous at college, the partygoers, the young professionals who go to the club,” as she put it.

“Routine testing at either emergency rooms or physicians’ offices,” she continued. “I think that’s our biggest chance of really catching people earlier.”