Mapping the End of HIV in the US

Heather Boerner

February 26, 2019

SEATTLE — The plan to end HIV by 2030 in the United States by targeting the hardest-hit regions with money and support, announced by President Donald Trump during his State of the Union address, is giving physicians new hope.

"We have infrastructure in place and boots on the ground to do implementation-type work," said Michael Mugavero, MD, from the University of Alabama at Birmingham.

"If the science can be matched with resources and political will, this could be the dawning of a new era" for HIV care in the United States, he told Medscape Medical News.

That "if" is top of mind for Mugavero as he heads to the Conference on Retroviruses and Opportunistic Infections (CROI) 2019. He and his colleagues throughout the Deep South have been addressing the issue for decades with little political support or money.

In his opening plenary, Anthony Fauci, MD, director of the National Institute of Allergies and Infectious Diseases and one of the formulators of the 2030 plan, said he will discuss the new plan in detail, from "why we think it will work, what are the end points and goals, and what is the scientific basis of how to implement it."

From Theory to Reality

It might be clear to anyone following HIV science in recent years that the plan could work. Study after study has shown that suppressive treatment prevents people infected with HIV from passing the virus on, as reported by Medscape Medical News. And the combination of emtricitabine and tenofovir (Truvada), when taken regularly as pre-exposure prophylaxis (PrEP), can prevent an uninfected person from acquiring the virus.

The fact that half of all new cases of HIV in 2016 and 2107 occurred in just 48 of the 3007 counties in the United States makes the increase in funding and programs for those specific counties and rural areas seem obvious.

"We have the scientific basis that theoretically — and we don't live in a theoretical world, we live in the real world — but theoretically, it ought to work," Fauci told Medscape Medical News.

Translating theory into practice is the challenge.

In a recent report, Heather Bradley, PhD, from the Georgia State University School of Public Health in Atlanta, and her colleagues estimated that even with current improvements in diagnosis, linkage to care, and continued engagement in care, 622,900 people will be diagnosed with HIV from 2018 to 2030 (AIDS Behav. Published online February 22, 2019).

If 95% of those people engage in care, 290,000 new HIV infections can be averted by 2030. But about 18,000 people would still be diagnosed with HIV in 2030.

However, if the United States can surpass the UNAIDS 90-90-90 goal and get to 95-95-95 — 95% of people infected with HIV knowing their status; 95% of those people on treatment; and 95% of those people with suppressed viral loads — and 20% of HIV infections are prevented with PrEP, by 2025, the number of people who acquire the virus could be less than the number of people living with HIV who die from any cause.

But this would require a 35% increase in the number of people in HIV care and a 3.3-fold increase in the number of people using PrEP. And right now, the gap in PrEP use between those eligible in black and Latino communities and those eligible in white communities, as reported by reported by Medscape Medical News, could derail that progress.

This, Bradley and her colleagues write, "would require substantial investment of resources and innovation in implementation models for reaching populations at highest risk for HIV infection — both at levels never seen before in the course of the US epidemic."

Financial and Political Commitment

When the president submits his budget proposal to Congress next month, it will include a dollar amount for the 2030 plan that will pay for scaled up care in the areas and communities hardest hit by HIV, Fauci said.

But don't expect the plan to duplicate what happens in New York City or San Francisco, he cautioned.

"This is the reason we're doing implementation research," he explained. "Things that work in San Francisco may not work in rural areas of Alabama. This is why we want to continue to observe how these areas are doing it and, if it works, amplify that."

This is exactly what physicians in the South are hoping to hear. Mugavero and his colleagues at Ryan White clinics in Alabama and Mississippi meet quarterly to talk about quality care. In so doing, they've built an infrastructure that allows providers and public health officials to identify their own hot spots of HIV transmission and funnel what resources they have into those communities.

The first strategy in the South to end HIV was developed by the Fulton County Task Force on HIV/AIDS in Atlanta.

"We want this national effort not to ignore the work we've done, but to help us expand it," said Melanie Thompson, MD, an HIV physician and principle investigator at the AIDS Research Consortium of Atlanta. "There are four counties in Georgia that are all in metro Atlanta that have been identified as key counties for this funding."

Thompson said her hope is that coordinated efforts of the Centers for Disease Control and Prevention, the Health Resources and Services Administration in the Department of Health and Human Services, and the National Institutes of Health start in community.

"Don't roll out the RFPs until you talk to those of us in the trenches," she said.

The trenches include community groups that serve people living with HIV and people in communities that will receive funds. At the University of Alabama, one of Mugavero's colleagues is working on a plan to roll PrEP out to those in greatest need, but not through a clinic. That clinic–community interaction, he said, might need to change.

"Any plan that is serious about ending the epidemic can't do so without being serious in supporting efforts in black America to make it happen," said Leisha McKinley-Beach, an HIV consultant with SisterLove, an Atlanta nonprofit, and the US Women and PrEP Working Group.

Communities of color are hardest hit by new HIV diagnoses right now, she said. And many of the counties that are part of the 2030 plan are primarily black, so concerns about healthcare and equity can't be ignored.

To end the HIV epidemic, Medicaid expansion and LGBTQ rights must be addressed and access to general healthcare, supportive services, and sexual and reproductive healthcare must be improved, McKinley-Beach explained.

We need "a full implementation of harm reduction to the opioid crisis, as well as the STD burden, in all communities, but especially Southern, rural, urban, black and brown communities," she said.

Fauci seems to agree. In a recent editorial explaining the plan, he and his coauthors emphasize the need for community involvement — in the form of local providers, public health agencies, and community organizations — to ensure the plan's success (JAMA. Published online February 7, 2019).

But Medicaid expansion and healthcare access are probably outside the purview of the plan as it stands now. "Some things are beyond our control," but those challenges "aren't going to slow us down," he said.

Learning From Others

Before the State of the Union address, Elaine Abrams, MD, a member of the CROI program committee, had been thinking about the conference as a promoter of important but incremental changes. There will be data presented on monthly injections for HIV treatment. There will be data on what happens when people live with HIV for 20 or 30 years.

Since the State of the Union address, though, she said the conference feels like it could be "a platform to bring together all this collaboration and learning and understanding, and then address some of the really tough issues that haven't had the funding or targeted attention to address."

In the United States, progress was being made in the elimination of HIV, "and then we just kind of left it," Abrams pointed out.

"We've eliminated mother-to-child transmission of HIV, or we've come close, and yet the epidemic persists, particularly in young men who have sex with men, particularly of color, or in groups where access to care or retention in care remain quite difficult," she said.

Increased funding of implementation science could teach physicians "to successfully engage populations we have not been able to attend to successfully," she added.

Some answers might come from data gathered abroad through Presidents Emergency Plan for AIDS Relief (PEPFAR) funding. There will be presentations at the meeting on the strides Thailand has made to end HIV and the HPTN 071 study on testing and treatment in Zambia.

In particular, the story of how Thailand reduced its HIV incidence "is a very nice story to inform what we do in, say, Alabama," said Abrams.

Mugavero reports receiving consulting fees from ViiV and Gilead Sciences. Thompson reports that her institution has received research funding from Bristol-Myers Squibb, CytoDyn, Gilead Sciences, GlaxoSmithKline, Merck Sharm Dohme, Roche Laboratories, Taimed, and ViiV Healthcare. Fauci and Abrams have disclosed no relevant financial relationships.

Follow Medscape on Twitter @Medscape and Heather Boerner @HeatherBoerner



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