In the midst of news surrounding the Trump administration’s plan to eradicate HIV/AIDS in the United States by 2030, the Centers for Disease Control and Prevention (CDC) that the annual decline in new HIV transmission rates has leveled off.
What does this mean for plans to combat the HIV/AIDS epidemic?
Experts say that the spotlight directed by the government coupled with gains made in prevention resources over the past decade signify a clear path forward to progress.
That being said, they stress significantly more needs to be done to make an HIV/AIDS-free future anything close to being a reality. Essentially, the current approach hasn’t worked.
“Right now, we have the tools to end the epidemic,” Dr. Ronald G. Collman, director of the Penn Center for AIDS Research in Philadelphia, Pennsylvania, told Healthline. “But we have to keep addressing how people have access to prevention and care, and the structures in our healthcare systems and communities both facilitate and make it difficult for people to get care, treatment and prevention — that is really how we need to focus our efforts.”
However, he added that it’s “important that we still continue to develop new strategies and continue on that quest for a cure.”
At the end of February, the CDC revealed that, based on the most recent data from 2010 to 2016, the number of reported new HIV cases leveled off in 2013 following what was seen as five years of significant drops in new diagnoses.
The number now stands at each year.
Beyond that total number, the CDC zeroed in further, showing that year-to-year HIV numbers declined in some populations, but in other communities more vulnerable to HIV transmission, the numbers increased.
In keeping with previous statistics, new cases were highest in men who have sex with men (MSM), accounting for 70 percent of new transmissions nationwide.
During that six-year period from 2010 to 2016, new cases decreased 16 percent among white MSM overall, remained stable among black MSM overall, but increased by 30 percent in Latino MSM overall.
Zooming in further, HIV transmissions decreased more than 30 percent in black MSM between 13 and 24 years old, stayed stable in Latino MSM of the same age, but increased a whopping 65 percent in black and Latino MSM ages 25 to 34.
Outside of the LGBTQ community, the numbers were down 17 percent in heterosexual men and women in total. This includes a 15 percent decrease in heterosexual African-American women.
New transmissions in people who inject drugs decreased by 30 percent.
The new release doesn’t specifically touch on transgender people, but show that from 2009 to 2014, 2,351 transgender people were reported to be diagnosed with HIV in the United States.
Collman said that while some numbers like the drop in new cases among men who have sex with men are encouraging, the transmission rates among Latinos and African-Americans show that increasingly more work needs to be done.
“When you start to look at race and age, even more stark disparities start to emerge,” he added. “I think as we look at the entire picture of the number of diagnoses in the United States, we have to maintain our focus on subgroups that are most impacted. As we make potential gains in one area, we have to ensure no one is left behind.”
Collman stressed that when discussing HIV, it is crucial not to frame it as some “generalized broad epidemic” without taking into account the role that the healthcare access, socioeconomic realities, and racial disparities that are part of affected communities play in shaping these statistics.
“More than half of infections are occurring in the southeastern part of the United States — this epidemic is not geographically uniform. Secondly, is that very large proportion of those affected populations are in the African-American community, particularly in young men who have sex with men,” Collman said.
He explained the need to target these populations by focusing on the large proportion of transmissions that occur from people who are newly diagnosed.
Nationally, about 20 percent of people living with HIV are unaware of their positive status, Collman said.
Even among those 80 percent that currently know, there was a period prior to their official diagnoses — the acute transmission phase — when the risk of transmission was higher.
He stressed that this is where the need to emphasize treatment as prevention comes in.
It’s important to have a system of rapid diagnosis and early identification so people who are newly living with HIV get immediate treatment and care.
Collman asserted that if the medical community is going to “control this epidemic” it isn’t just about giving people therapies, it’s about giving them those therapies “fast and get them on treatment right away” before the virus may be transmitted to others.
Dr. Hyman Scott, MPH, the clinical research medical director at Bridge HIV and an assistant clinical professor of medicine at the University of California, San Francisco (UCSF), told Healthline that outreach to particularly vulnerable communities is key.
He said while these national figures are important, it is all about local outreach.
For him, the big questions are: how do we get better access to communities locally, how do we bridge some of these racial and economic disparities, and how do we get the best treatment to those who have been diagnosed?
“These are not ‘hard-to-reach’ populations, but instead these are ‘hard-to-reach’ services for these populations,” he said. “We need to be re-framing our perspective on why individuals might not engage with the services. We need to better understand why and how these services need to be restructured.”
Scott works in San Francisco and said locally, from his perspective, one of the biggest issues he sees is healthcare access.
He said that one of the biggest ways to lower the number of new diagnoses would be expanding Medicaid services and offering expanded access to prevention methods like pre-exposure prophylaxis (PrEP).
PrEP is a treatment of two medications in one pill that is prescribed to be taken daily by people who are HIV-negative and at risk for contracting HIV.
Similarly, he said it is crucial to better enable people who are living with HIV to get the antiretroviral treatments they need to manage their condition and stay healthy.
Access to antiretroviral therapy is important given that it has led to major drops in HIV- and AIDS-related deaths since the height of the epidemic in the 1990s.
The CDC that if people who are living with HIV stick to an antiretroviral therapy regimen, they can reach an “undetectable” viral count, which means they can’t effectively transmit the virus to their sexual partners.
Scott added that there is no one-size-fits-all solution. The best way to combat HIV is to combine multiple tactics to reach at-risk communities.
“There is no silver bullet,” Scott said. “We have the tools to really end the epidemic and we have to use them and expand them and ensure people have access to them. We have to make sure these tools can fit into these people’s lives if that’s what it required in order to ensure we can make these changes to fight the epidemic.”
Truvada is the brand name for PrEP in the United States, and is the only HIV-prevention drug sanctioned by the Food and Drug Administration right now in the country.
Truvada’s domestic manufacturer, Gilead Sciences, has come under fire due to its continuously escalating out-of-pocket costs.
The list price for a 30-day supply is currently $2,000. While Gilead provides a co-pay coupon assistance program to help customers who are commercially insured pay for it, advocacy groups like ACT UP have been clear in their opposition to the company’s tactics that they feel prevent the drug from being accessible to those most in need.
Scott explained that some major cities in the country have established programs to make this prevention regimen accessible, but “a lot of people still have barriers to accessing PrEP.”
Dr. Kristin Englund, an infectious disease expert at Cleveland Clinic, told Healthline that more needs to be done when it comes to dispersing informational campaigns about PrEP to HIV-vulnerable communities.
Also, continued education about the use of condoms during sex is vitally important. When used correctly, condoms are one of the ways to protect against HIV and other sexually transmitted infections (STIs).
Beyond that, she said more needs to be done to educate the medical community itself.
“Folks practicing in areas where they have patients who are high-risk, well, we have to be making them aware of the need to be asking these questions of their patients, to provide them with PrEP, as well offer a multi-pronged informational push to make everybody aware of their risk (of HIV) and where they can go for treatment,” Englund said.
She added that everyone should always discuss with their doctor what medication is right for them.
People who go on PrEP are given the same standard recommendation in general — they have to come in for doctor visits every three months, to monitor whether they are experiencing any side effects and to receive testing for HIV and sexually transmitted infections.
Englund said that another issue of access revolves around some of the youngest members of the population who are at risk for contracting HIV.
She said, so far, only Connecticut is looking into legislation that would waive the requirement for adolescents under the age of 18 to need a guardian’s or parent’s consent to go on PrEP.
However, she pointed out this doesn’t address the big question of cost. If a young person is given easier access to HIV prevention tools without a guardian’s consent, how do they pay for it?
“An adolescent or young adult may be on a parent’s health insurance. It is exceptionally difficult to address how these young people could pay for such a treatment without guardian support,” Englund added. “We need to make sure that finances and access aren’t as much a barrier for people to be able to protect themselves.”
During his State of the Union Address last month, President Donald Trump said his administration would be launching an initiative to eradicate HIV by 2030.
The Health and Human Services Secretary Alex Azar wrote in a statement that this is “a once-in-a-generation opportunity to end the epidemic, thanks to the most powerful HIV prevention and treatment tools in history and new tools that allow us to pinpoint where HIV infections are spreading most rapidly.”
The administration’s four-pronged plan, involves the strategies emphasized by Collman, Scott, Englund, and their peers — diagnosing HIV as early as possible, treating it rapidly to achieve viral suppression and “undetectable” status, protecting at-risk populations with PrEP, and responding rapidly to “growing HIV clusters,” .
Collman added that this needs to be an era of creativity, where “new ideas need to be developed to really move us ahead substantially from where we are.”
Scott stressed that economics need to be a big part of the equation of addressing HIV prevention.
If efforts aren’t made to enable prevention for HIV-negative — but at-risk people — and treatment for people living with HIV to be accessible and affordable, the gains we need to see won’t be achieved.
One thing critics have pointed to is the lack of specificity in the State of the Union Address. The President did not mention how much funding would be allocated to this kind of wide-ranging initiative in his speech.
Nevertheless, Englund said she is “very optimistic” that we will start to see a “decline in rates of new HIV cases as we get more and more awareness” out there.
“I think one thing we need, is to have funding in the national budget. Not only funding in this budget for this year, but for something like this to be funded every year. It needs funding every year for us to truly be able to reach this success,” Englund said.
She pointed out that money was diverted away from HIV research and care in the 2018 budget.
“It can’t be a ‘ping pong experiment.’ Are we going to take care of HIV this year or not? This is a big task and an important task and we need it to be a long-term commitment.”
Just weeks after President Donald Trump announced a pledge to eradicate new HIV cases from the United States by 2030, the Centers for Disease Control and Prevention (CDC) that the annual decline in new HIV transmission rates has leveled off.
Right now, the number of new transmissions stands at 39,000 each year.
Medical experts say that more needs to be done to make HIV prevention tools like pre-exposure prophylaxis (PrEP) and antiretroviral treatment for people who do have HIV more accessible.
Major barriers like skyrocketing health insurance costs and lack of education and awareness of ways to protect against and treat the virus leave some vulnerable populations particularly at risk.
This causes disparities between more affluent white communities and poorer African-American and Latino communities.