DENVER -- Putting HIV patients on treatment is like a mortgage -- the more you pay now, the less you pay later.
That's the analogy Julio Montaner, MD, of the University of British Columbia in Vancouver, used here at the American Conference on Treatment for HIV to emphasis the argument for universal treatment for today's HIV patients.
Universal treatement is "a real game-changer" that could dramatically slow transmission of the virus and the progress of the pandemic and that, in turn, would mean fewer future patients needing lifelong -- and costly -- treatment for HIV and its associated co-morbidities, Montaner said.
Expanding antiretroviral therapy as far as possible would be good for HIV patients since recent evidence suggests that earlier treatment improves long-term outcomes, Montaner, a former president of the International AIDS Society, told attendees at the opening plenary session.
But there is a "very compelling body of evidence" that such widespread treatment would also reduce the number of new cases of HIV, he said.
That, in turn, would make the initial investment a cost-saving measure.
In British Columbia, for example, he said the advent of highly active anti-retroviral therapy (HAART) -- available to all patients at no cost -- reduced new cases from 800 a year to 400.
Under the conservative estimate that life-long medical management of an HIV patient costs $250,000, that 400-case "deficit" saved the Canadian province some $100 million, Montaner said.
Current U.S. guidelines for treatment say that as many as 80% to 90% of people with HIV should be placed on treatment, Montaner told 鶹ý later.
"Why have we not implemented those guidelines? People say it would cost of lot of money," he said, "but we need to re-think the cost-effectiveness equation."
The "secondary benefit" of HIV prevention would mean that universal treatment would eventually save money, he said.
Current treatment guidelines in the U.S. are "permissive" toward treatment of most people with HIV, according to John Brooks, MD, of the CDC and one of the conference co-chairs.
But actually getting people on treatment and keeping them there remains challenging, not only because of barriers associated with the treatment itself, Brooks told 鶹ý, but also because of cost.
In many places, waiting lists for drug therapy are growing, he noted, despite federal support under the Ryan White CARE Act.
Cost is "a tough issue" that would be difficult to overcome even in rosier economic times, Brooks said. "It's hard to explain to people that the upfront cost is worth the long-term investment," he said.
He added that he found Montaner's mortgage analogy "appealing."
Montaner told conference participants that in British Columbia the number of new HIV diagnoses per year is continuing to fall as the number of people on active HAART climbs.
But he also noted that several studies in so-called sero-discordant couples -- in which one partner has HIV -- have shown that HIV treatment reduces the risk of transmitting the virus by more than 90%.
HAART in the U.S., Canada, and the rest of the developed world has also been shown to almost eliminate the risk of HIV-positive women passing the virus on to their infants.
In general, he said, an undetectable HIV viral load is associated with very small risk of transmitting the virus.
But in the U.S., according to a recent analysis, less than 20% of diagnosed HIV patients have reached such a level, while nearly half are not yet on HAART, Montaner said.
A universal treatment strategy -- dubbed "test-and-treat" -- is being studied in Washington and New York City, and will be examined in four other cities as well.
The main goal is determine what's needed to find people at risk for HIV, test them, treat those with the virus, and retain them in care so that they eventually have an undetectable viral load.