I have seen the future of the global fight against HIV/AIDS and it is New York City.

One of the most fascinating developments this World AIDS Day has not come from Africa, Asia, or  even Washington, DC.  Rather, it was an anodyne announcement from the New York City health commissioner Thomas Farley this morning who said that anti-retrovirals should be made available to anyone as soon as they are diagnosed with HIV.

To understand the significance of this announcement you have to know a little bit about treating HIV. When someone contracts HIV, they do not go on ARV treatment right away. Rather, that person must wait until his or her CD4 count reaches a certain threshold. In the USA, this is a standard set by the Centers for Disease Control. In most of the developing world, the standard is set by the World Health Organization. Both the CDC and WHO don’t recommend that infected people go on treatment right away because once  ARV treatments begin, the person living with HIV has to keep taking these drugs for the rest of his or her life. Better to delay that as long as possible.

The thing is, there a series of scientific studies published this year show that putting people living with HIV on ARVs sooner can significantly reduce the chances that they will spread the virus. One study even shows that people who are not HIV positive, but have an HIV positive partner, can use ARVs as a prophylactic.

This is the future of HIV prevention efforts. Pretty soon, the CDC will adopt these guidelines. And not long after that, the World Health Organization will come around to it as well. The problem from a public health perspective is that these decisions come with a big price tag. Millions of new people will suddenly become eligible for treatment.

New York City can handle the cost. And they are doing the right thing by letting the latest science drive the city’s HIV prevention strategy. But if this prevention effort is good enough for New Yorkers, then why not in even larger cities like Lagos or Nairobi? Unfortunately, the money just isn’t there.  We can’t even reach about 15 million people who are eligible for treatment under current guidelines, let alone more expansive ones.

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