New federal policies sought to reflect HIV treatment gains

Two physician groups are urging the federal government to update policies related to HIV infections, charging that the policies were drafted years ago when infection with the virus equaled a death sentence.

Now, with appropriate treatment, people infected with HIV can live a near-normal life span, noted Michael Saag, MD, chair-elect of the Infectious Diseases Society of America's HIV Medicine Assn. He spoke during an April 17 press briefing to introduce a joint position paper of the American College of Physicians and the HIVMA. The paper was released online April 16 and is to be published in the May 15 Clinical Infectious Diseases.

In their paper, the groups call for earlier identification of those infected with the virus, expanded access to treatment and stronger national leadership to respond to HIV's spread in the United States and abroad.

Gains on HIV diagnosis and treatment have made it more important to identify people carrying the virus as early as possible, the position paper said. Yet recent estimates by the Centers for Disease Control and Prevention say that of the 1.1 million people in the U.S. infected, one in five is unaware of his or her status.

Because of near-universal testing and implementation of effective treatments for infected mothers-to-be, transmission to infants has basically stopped, Dr. Saag said. "Now this same concept needs to be applied to the entire population."

Another reason for rapid identification and treatment is a recent finding that the AIDS virus is now more virulent, and damage to patients' immune systems is occurring earlier.

A paper published May 1 in Clinical Infectious Diseases found that 25% of patients diagnosed with HIV in recent years already had CD4 cell counts of less than 350, which is the threshold for implementing antiretroviral therapy, compared with only 12% of patients in the late 1980s.

"Unfortunately, it may no longer be true that there is a time period of several years between diagnosis and the need for treatment -- instead, this time span is shortening," said study author Nancy Crum-Cianflone, MD, MPH, an infectious diseases specialist at San Diego Naval Medical Center.

Broad screening urged

Although the CDC put out a call in 2006 urging widespread HIV screening, the response has been spotty from the nation's hospitals, clinics and physicians' offices. The AMA also recommends that physicians routinely test adult patients.

Among the changes requested by the ACP and the HIVMA are those allowing reimbursement for the screening of all patients in federal health programs. "Although the Centers for Medicare & Medicaid Services are considering reimbursing the cost for testing high-risk patients, we would recommend they expand this policy to cover all Medicare beneficiaries," said Jeffrey Harris, MD, ACP's immediate past president.

The cost of treatment increases dramatically in later stages of infection, he noted. With early treatment, the cost is less than $14,000 per year, but that figure increases to more than $36,000 annually, he said.

The groups also request the expansion of proven prevention strategies. "It's time to support evidence-based transmission prevention efforts such as needle-exchange programs and comprehensive sexual education," said Kathleen Squires, MD, HIVMA vice chair. Despite studies showing the effectiveness of needle-exchange programs, the federal government does not support them, she said.

J. Fred Ralston, MD, president-elect of the ACP said work force issues also must be addressed.

Screening is going to be done by primary care physicians, and that network is "in critical condition as we speak," he said. "It has been shown that the collapse of primary care is going to lead to higher costs, lower quality, diminished access and decreased patient satisfaction, which is certainly not the direction in which we want to head."