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Gaps in testing and treatment spur HIV transmission


CDC director Dr. Robert Redfield. Photo: Courtesy Institute of Human Virology/University of Maryland School of Medicine
CDC director Dr. Robert Redfield. Photo: Courtesy Institute of Human Virology/University of Maryland School of Medicine  

Around 80 percent of new HIV infections are attributable to people who either do not know their status or are not receiving treatment to suppress viral load, according to a new report from the Centers for Disease Control and Prevention presented at the National HIV Prevention Conference last week in Atlanta.

"If we increase access to testing and treatment for HIV infection, we can prevent a lion's share of new infections in this country," CDC director Dr. Robert Redfield said during a March 18 press telebriefing to launch the report. "Studies show that people with HIV who are virally suppressed not only live longer, healthier lives, but they also have effectively no risk of transmitting the virus to sexual partners. The bottom line is HIV treatment saves lives and prevents new infections."

Redfield spoke at the opening session of the conference the same day, discussing the Trump administration's new Ending the HIV Epidemic plan, introduced during the president's February 5 State of the Union address.

As previously reported, the plan — which is allocated $291 million in Trump's proposed budget for 2020 — aims to reduce new infections by 75 percent within five years and by 90 percent within 10 years. It will focus on around 50 counties with the highest HIV burden and seven states with disproportionately high rural HIV rates. Expanded testing, prompt antiretroviral treatment, and PrEP are key elements of the plan.

New infections stalled
After a dramatic decline in the late 1990s, the number of new HIV infections nationwide has stalled in recent years at around 40,000 annually. According to the latest Vital Signs report, just over half of people living with HIV in the United States are aware of their status, receiving care, taking antiretroviral therapy, and have an undetectable viral load.

Among the other half, the 15 percent who do not know they have HIV accounted for 38 percent of new infections, according to CDC estimates. Another 23 percent know they are HIV-positive but are not in care, accounting for 43 percent of transmissions. Finally, 11 percent are in care but have not achieved viral suppression, accounting for an estimated 20 percent of transmissions. Men who have sex with men had the highest transmission rate, accounting for 73 percent of new infections.

"To address the 43 percent of transmissions that occur from the 23 percent of persons who have diagnosed infection and are not in care, improvements in rapid linkage to and retention in care are needed," the report authors wrote. "Community efforts to increase public awareness of the benefits of viral suppression might help decrease stigma and make staying in care easier."

As part of the effort to end new infections, the CDC recommends that everyone age 13 to 64 should be tested for HIV at least once, and those at high risk should be tested at least once a year. People diagnosed with HIV should start treatment as soon as possible, regardless of CD4 T cell count — an approach pioneered in San Francisco back in 2010.

Redfield told reporters that many people who are unaware of their HIV status are seeing health care providers but not being tested, which he dubbed "diagnostic complacency." This gap might be addressed by non-traditional approaches such as making testing kits available over the internet, he suggested.

Dr. Jonathan Mermin, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, emphasized that the tools and knowledge needed to end the epidemic are available, but they must be appropriately applied.

"Today, we have the tools to end the HIV epidemic, but a tool is only useful if it's in someone's hands," Mermin told reporters. "These data emphasize why it's vital to bring testing and treatment to people with HIV. We can empower them to take control of their lives and change the course of the epidemic. We will need to deliver these interventions and other proven tools like PrEP, condoms, and syringe service programs to the individuals and communities where they are most needed if we are to end the HIV epidemic in this country."

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