Treatment and prevention are important, but an HIV cure will be the true end of AIDS
by Jeannie Wraight
Lately, we have been hearing a lot about the end of AIDS. Not by a cure but by targeted prevention and treatment measures to reduce the spread of HIV, including treatment as prevention (TasP) and the reduction of community viral load, the countdown to zero (eliminating new mother-to-child transmissions), the use of PrEP, etc.
Despite optimistic catch phrases, cheery public service announcements, high-level political rhetoric, and articles announcing “the end of AIDS,” the cold hard statistics tell a different story. Yes, we have had some hard-earned victories in reducing new infections that we should feel happy and accomplished about, but, particularly here in the U.S., reality in the form of a CDC report is screaming “this is not the end of AIDS.”
Despite the effectiveness of third-generation antiretrovirals (ARVs) in reducing HIV viral loads to undetectable levels, new statistics show disappointing results in U.S. HIV patients. A recent CDC report found that only three in every ten Americans living with HIV had an undetectable viral load in 2011. Although disparaging, it should be noted that some progress has been made nationwide, as 2009 statistics found twenty-six percent to be undetectable, four percent less than in 2011.
The report found that of the 1.2 million people presently living with HIV:
• Twenty percent did not know they are infected
• 840,000 were not consistently taking ARVs.
• Sixty-six percent were not in regular care
• Ten percent were unable to maintain an undetectable viral load despite being on ARVs
• Four percent were receiving care from a physician but were not on ARVs
Men who have sex with men account for a large percentage of those in the U.S. living with HIV, but an earlier CDC report found that of gay men living with HIV, only fifty-one percent were receiving care and only forty-nine percent were on antiretroviral treatment.
HIV-positive people ages eighteen to twenty-four fared the worst in regard to viral suppression, with only thirteen percent with viral loads below the level of detection. Compare this rate to those living with HIV/AIDS across other age groups: viral suppression was twenty-three percent for those ages twenty-five to thirty-four; twenty-seven percent in the thirty-five to forty-four age group; thirty-four percent in the forty-five to fifty-four; thirty-six percent in people fifty-five to sixty-four; and thirty-seven percent in those over the age of sixty-five.
Interim data released this past March at the Conference on Retroviruses and Opportunistic Infections (CROI 2014) confirmed the importance of a suppressed viral load, not only to an individual on ARVs but also to their partners and public health in general. The PARTNERS study found that no one who participated in the large study who had an HIV viral load under 200 copies transmitted HIV to their partner. This included transmission through both anal and vaginal sex.
The PARTNERS study echoed the results of HPTN052, which found a ninety-six-percent reduction in risk when the HIV-positive partner in serodiscordant couples (one partner HIV-positive, one partner HIV-negative) was on ARVs.
With rates of viral suppression so low, a great deal of focus has been invested in the HIV care continuum, a model used to find issues that prevent HIV-positive people from receiving adequate care resulting in viral suppression. There are five steps to the care continuum: HIV diagnosis, linkage to care, retention in care, receiving and staying on antiretroviral treatment, and viral load suppression. Researchers have identified that, across the spectrum of engagement in care, there are many more individuals diagnosed with HIV than have reached viral load suppression. This is called the “treatment cascade”—the numbers fall off along the steps of care, from one end of the continuum to the other.
One method of enhancing the care continuum in New York City was described in a recent issue of the on-line edition of Clinical Infectious Diseases. In an attempt to improve the care continuum, New York City’s Ryan White Part A HIV Care Coordination Program was launched in 2009 to determine its short-term success at providing additional support to improve clinical outcomes for individuals either newly diagnosed or with prior poor HIV-related outcomes.
Services offered included: individual case management, follow-up after missed appointments, a multidisciplinary care team, accompanied clinic visits, and adherence support.
Results showed that for those newly diagnosed, ninety-one percent remained engaged in care over the year they were followed and sixty-six percent had a suppressed viral load under 200 copies/ml.
For those who were not newly diagnosed, engagement in care increased from seventy-four percent to ninety-one percent, with fifty-one percent virally suppressed.
Programs such as this initiative must be supported if we are to achieve better rates of viral load suppression in order to both improve the health of people already living with HIV and to reduce the number of new HIV infections nationally.
Statistics such as those reported in the CDC report should be a clear reality check. HIV will not be eliminated purely through prevention and current treatment options, and a preventative vaccine will only avert new infections. The development of an HIV cure is the only hope for us seeing an end to AIDS for us all. Let us work hard in 2015 to get us closer to this goal.
Jeannie Wraight is the former editor-in-chief and co-founder of HIV and HCV Haven (www.hivhaven.com) and a blogger and writer for TheBody. com. She is a member of the Board of Directors of Health People, a community-based organization in the South Bronx and an advisor to TRW (Teach me to Read and Write), a community-based organization in Kampala, Uganda. She lives with her husband in New York City.