Study in D.C. to test whether HIV treatment can prevent spread
NIH to offer tools to improve patient tracking, follow-up

By Darryl Fears
Washington Post Staff Writer
Friday, November 13, 2009

The National Institutes of Health and the D.C. Health Department are preparing to launch a study in the District with an ambitious goal: to determine whether aggressive treatment of every adult with HIV could eliminate AIDS.

As part of the study, the NIH will provide the Health Department with experts who will help modernize patient record-keeping at clinics to better track HIV-infected people. Experts will also show social workers how to monitor patients to ensure they take their medication, even when they feel well.

"The purpose is to get the . . . level [of HIV in the blood] down so that people will not infect anyone because their viral load is so low," said Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. "When you follow couples -- one who's infected, the other who's not -- the probability of infection diminishes when the viral load is very low. The philosophy is if you could test everybody, and treat everybody who has HIV, you could use treatment as prevention."

Fauci declined to say how much money and other resources would be devoted to the study before the project begins next month. He and city officials also would not to say which areas of the city would be included in the study, aside from Anacostia.

In the District and other cities, about half of the people who are tested and receive an HIV diagnosis wait an average of six months before getting treatment. During that time, many carry on as if there was no diagnosis, using illegal drugs and having unsafe sex, spreading the virus and sometimes re-infecting themselves with a deadlier strain of the disease.

Fauci said the premise for the study is based on a mathematical theory put forward by doctors at the World Health Organization last year. They concluded that global universal treatment with antiretroviral drugs would reduce HIV to 1 case in 1,000 by 2016 and reduce the prevalence rate -- which includes an estimation of the number of people with HIV who have not been tested -- to 1 percent in 50 years.

The report energized U.S. doctors and scientists who study AIDS because it was the first to look at aggressive treatment as prevention, a way to arrest the spread of the disease in a community, such as Anacostia. A similar study is being conducted in the Bronx in New York.

But the WHO theory is so untested that its supporters doubt it will live up to expectations. "It's so far in the hypothetical stage that I wouldn't even rank it" among the methods that work, such as condoms and needle exchange, Fauci said.

The study, scheduled to be launched by the White House on or around World AIDS Day, Dec. 1, has major challenges. Researchers must first determine whether testing every adult for HIV is feasible. Then they must determine whether people who test positive will opt for treatment.

"They might say, 'I don't want to go on medication, I feel fine,' " Fauci said. "What happens when you treat people? Will the benefit equal a benefit to society? Will aggressive treatment have the unintended consequence of inducing drug resistance? Will it lead to behavior changes with people running around doing what they want, assuming they're disease-free? We might find that this is not workable."

If the theory is proved, Fauci said, it could lead to a nationwide testing and treatment program for adults 18 to 49 that would cost hundreds of millions, "if not billions," of dollars.

Some doctors have said the study's premise is shaky because the WHO theory is not valid. Elimination of HIV is theoretically possible, "but it would take at least 70 years" based on the WHO model, said scholar Bradley G. Wagner and Prof. Sally Blower at the David Geffen School of Medicine at the University of California at Los Angeles.

"Even under optimistic assumptions, we find elimination to be unlikely," the authors wrote in a study of the WHO theory. But Wagner and Blower, who have said they were among the first to suggest treatment as a prevention method 10 years ago, said the WHO model is useful, with lower expectations.

Doctors at the University of North Carolina were also skeptical, calling the WHO theory plausible but unproved. However, Prof. Myron S. Cohen and two colleagues wrote, "The WHO model challenges us to marry treatment and prevention."

At the Family and Medical Counseling Service, a primary care clinic in Anacostia, deputy director Angela Fulwood Wood embraced the WHO theory and the NIH study that aims to prove it. "We're missing opportunities to deal with HIV as early as possible," she said.

The clinic caters to African Americans in a high-risk area for HIV contraction and could use the tools offered by the NIH -- electronic patient records and personnel who could follow up when people test positive.

Follow-up requires persistence and personnel, the latter a resource the clinic does not have in abundance, Wood said. The clinic needs trained counselors to overcome an anti-medical establishment mind-set in Anacostia. "As African Americans, we are very proud to not take medicine, especially if we don't feel sick."

Corrie Franks, 55, said he waited five years to get treatment after his HIV diagnosis at a New York prison in 1990.

Released from prison four months later, he behaved no differently, smoking crack and having sex. He moved to the District in 1995, entered a drug rehabilitation facility, heard a presentation from the counseling service and got treatment.

"I went from a high viral load to an undetectable viral load," he said.

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