A Generation Free of HIV

Early HIV treatment extended patients’ lives by six to nine years and prevented nearly 190,000 new HIV cases in the U.S. between 1996 and 2009, according to a series of research papers published today in Health Affairs.

In fact, researchers suggest in one paper that a generation free of HIV could become a reality if scientific advances continue and policies are put in place to ensure that HIV patients have access to healthcare and stick to their treatment programs.

“There is reason to be hopeful that we can move a long way in that direction,” says John A. Romley, Ph.D., an assistant professor at the University of Southern California's Price School of Public Policy and an economist at the Leonard D. Schaeffer Center for Health Policy and Economics, who co-authored four of the new papers.

There are more than one million people in the U.S. living with HIV/AIDS. Romley explains that a “generation free of HIV” means that over time, HIV would become very rare. “It’s something that would happen gradually,” he adds. “To have that prospect in sight is a wonderful thing.”

However, Romley notes that there are still significant barriers to overcome. As of 2010, only 17 percent of people living with HIV/AIDS had private health insurance. And while the Affordable Care Act (ACA), better known as Obamacare, could expand access to testing and early treatment, the researchers are concerned that existing care programs could face budget cuts.    

Taken as a whole, the new research—which includes contributions from scientists at the USC Schaeffer Center for Health Policy and Economics; the University of California, Los Angeles; Stanford University; and Bristol-Meyers Squibb—highlights the benefits of early HIV treatment and advocates for policies to ensure that those who need it get it.

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Adding Years to Patients’ Lives

In two studies on life expectancy and the prevention of new HIV cases, the researchers focused on the period between 1996—the year a highly effective treatment known as combination antiretroviral therapy (cART) became available—and 2009, when U.S. medical guidelines began recommending cART at earlier stages of the disease.

The stages of HIV are determined based on a patient’s CD4 white blood cell count, measured per milliliter of blood. Falling CD4 counts mean that the disease is worsening.  

Since being introduced, cART has been the standard treatment for patients with advanced HIV, who have CD4 counts below 350. However, the new research examined the benefits of cART for patients who received “early treatment” when their CD4 counts were between 350 and 500.

“There was reason to believe [in 1996] that early treatment could be beneficial, and some doctors were recommending it,” notes Romley.

Starting treatment early added years to HIV patients’ lives. The researchers estimate that patients who received early treatment gained six years of life, compared to those who waited until their CD4 counts fell below 350. Patients who had “very early” treatment—at CD4 counts above 500—experienced even greater benefits: an additional nine years of life.

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Nearly 25 Percent Fewer HIV Cases

To determine how many HIV cases cART prevented during the study period, researchers used a model that predicts the incidence of HIV based on sexual transmission and progression of the disease. The study assumes—conservatively, based on past research—that a patient who receives cART is 90 percent less infectious than an untreated person with early-stage HIV.      

The findings highlight the benefits of cART: without early treatment, the model predicts that there would have been 962,000 new HIV cases between 1996 and 2009. The actual number was nearly 25 percent lower, at roughly 772,500 new cases. “Very early” treatment accounted for four-fifths of the prevented cases.  

“Because some people with HIV got treatment early, [from] 1996 to 2009, almost 190,000 people in the U.S. never had to bear the burden of HIV, nor their families and loved ones,” says Romley.

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The “Test and Treat” Strategy

Scientific advances like cART have led to the development of the “test and treat” strategy for reducing the spread of HIV. In one of the new papers, the researchers claim, “these changes raise the prospect that for the first time since the 1980s, an entire generation might be free of HIV.”

The basic idea of the test and treat strategy, Romney explains, is to implement widespread testing to reach the more than 18 percent of people with HIV/AIDS who don’t know they have it. Once diagnosed, the goal is for patients to start cART immediately and stay in treatment.

However, of the 1.1 million people living with HIV or AIDS in the U.S., only one in three is currently receiving cART.

“We need to encourage greater testing," says Romley. "For people who test positive, we need to make sure they get linked to good doctors who will see them regularly. We need to make sure they have access to treatment in the form of antiretroviral therapy.”

There is evidence that the test and treat strategy is effective. One of the new studies found that a strategy focused on getting HIV patients to start and stick with treatment is the most likely to meet public health goals in Los Angeles County, including reducing the number of new HIV infections.

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The Promise—and Pitfalls—of the ACA

Lack of health insurance is a barrier that keeps people with HIV from starting and adhering to treatment, the researchers note.

The ACA has the potential to improve access to testing and early treatment. One of the new studies found that the ACA will result in nearly 500,000 more people being tested for HIV by 2017, along with a 22 percent drop in the proportion of people who don’t know they have HIV.

However, in another new study, researchers note that nearly 60,000 uninsured, low-income people with HIV/AIDS live in states that have opted not to expand Medicaid under the ACAIf people in this group can’t access early treatment, the evidence suggests that they will lose multiple years of life, Romley says.

“People don’t think of Medicaid as gold-plated insurance—and it isn’t,” adds Romley, “but the evidence is that even modest public insurance has benefits relative to not having insurance for the HIV population.”

One alternative is the federal Ryan White Program, which serves more than 500,000 HIV/AIDS patients each year, operating as a “payer of last-resort” to facilitate access to cART and other services. However, Romley says that the program isn’t as comprehensive as Medicaid and that some states have waiting lists.

There is also concern among healthcare providers that once the ACA is fully implemented, lawmakers may cutback or terminate the Ryan White Program.

In addition to cART, the program offers important secondary services that health insurance doesn’t usually provide, such as case management and housing supplements. These services help patients stay healthy and in treatment.

“Even as we move toward—maybe not quite getting there, but substantially toward—universal coverage in the U.S., the Ryan White program should not be forgotten,” says Romley.  

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