But now a number of studies suggest that people whose

But now a number of studies suggest that people whose CD4s are allowed to drop that low are destined to poorer outcomes. At an AIDS conference earlier this year, researchers from Seattle presented a large-scale study that compared patients who started treatment early with those who waited. They found delaying therapy boosted the odds of dying by either 69 percent or 94 percent over a decade, depending on how low the patient’s T-cell count was. These are staggering numbers. Though the investigators say that randomized long-term studies are needed to confirm their work, they nonetheless propose beginning treatment earlier. Leading AIDS doctors are persuaded. “Many of us who see large numbers of HIV patients are becoming superaggressive,” says Dr. Stephen Dillon, who practices in the West Village. “I don’t believe everybody needs to be started on meds. But I do believe that we need to start earlier than we have been for the last five to ten years.”

In a dramatic move last week, the National Institute of Allergy and Infectious Diseases upped the ante even further by announcing a massive new plan to test virtually every single adult in the Bronx and the District of Columbia—homes to some of the highest rates of infection in the country—and put everybody who tests positive on anti-HIV drugs, whether they have depleted T-cell counts or not. Dr. Anthony Fauci, the nation’s top AIDS official, said the main goal of the program was to stem transmission of the virus. Untreated patients are extremely infectious. Effective treatment suppresses HIV to such a degree that transmission risks can be virtually eliminated.

Still, the proposal is fraught with ethical peril. Because of the stigma associated with HIV infection, advocates have long insisted that testing for HIV should only be done in combination with extensive counseling. In addition, a number of leading researchers have called for more research on the drugs’ side-effects before putting more people on them, according to Jeffrey Laurence, a professor of medicine at Weill Cornell Medical College in New York. For one thing, he says doctors wonder if African Americans fare worse on the drugs than whites. “Our chairman of medicine said he’s never seen a white person with HIV and kidney disease, it basically doesn’t happen. There’s a whole bunch of information we need before pushing forward with this.”