Fauci says routine HIV testing critical

Fauci says routine HIV testing critical

Early recognition could stem tide of U.S. epidemic

New public health recommendations to routinely test people for HIV will have a significant impact on the AIDS epidemic, said Anthony Fauci, MD, director of the National Institute for Allergy and Infectious Diseases.

"We know that over 60% of new infections are transmitted by someone in an acute state of infection," he said recently in San Francisco as keynote speaker at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). "Which is why the recent CDC guidelines are so critically important. I think we will make great strides now that we routinely test people for HIV."

The Centers for Disease Control and Prevention has issued new recommendations for health care providers that are designed to make voluntary HIV screening a routine part of medical care for all patients ages 13 to 64. Despite prior CDC recommendations for routine testing for high-risk individuals and for all patients in settings with high HIV prevalence, many patients with unrecognized HIV infection access health care but are never tested for HIV. The recommendations emphasize that HIV testing must be voluntary and undertaken only with the patient's knowledge. However, the CDC is shifting to an "opt-out" approach that tilts the default position more toward routine HIV testing.

The recommendations aim to simplify the HIV testing process in health care settings and increase early HIV diagnosis among the estimated more than 250,000 HIV-positive Americans who are unaware of their infection. With dramatic results possible in those undergoing antiretroviral therapy, knowledge of infection — particularly in the early stages — is more important than ever.

"If you look at antiretroviral therapy and treatment, prevention of opportunistic diseases and mother-to-child transmission prevention, we have saved approximately 3 million years of life in the United States," Fauci said. "That is a resounding success story, but we can't rest on our laurels. . . . Although this started off with a handful of cases in California and New York, this is a global problem. Even though we still have great challenges here, this is fundamentally a problem of the developing world."

While trying to project AIDS prevention goals for the next decade, Fauci paused for a moment to look back at the havoc that has been wreaked since the CDC reported the first cases in 1981.

"I don't think any of us could have possibly imagined in our wildest dreams how [AIDS] could have exploded the way it exploded," Fauci said. "Those of us in the arena of microbiology and infectious diseases sometimes don't appreciate that we are in unique position historically. We have been living through one of the most important catastrophic public health events in the history of civilization. This is truly catastrophic — 60 million [global] cases thus far, with 25 million deaths and about 40 million living with HIV. The number of new infections — 4 million this past year — immediately tells us what one of our goals needs to be over the next 10 years."

The global challenge, search for vaccine

Unless the number of new infections can be lowered, even achieving a near miraculous goal of universal antiretroviral treatment in the developing world won't be enough to stem the tide. Hard-earned progress has been made, with some 1.6 million people in the Third World receiving antiretroviral therapy.

"Just a few years ago, that was measured in the few thousands," Fauci said. "But we still have a long way to go. Only 25% of people who need [the drugs] get them. Striving for universal access is a public and ethical imperative; however, with the current rate of new infections, it is going to be logistically impossible to reach the goal for universal treatment."

There is little immediate hope of vaccine development, though the next decade should show whether it is going to be possible to at least create a partially effective vaccine that could slow disease progression and/or lower transmissibility.

What is needed in the next decade is a greater understanding of the early events in HIV because that is the period when intervention is most likely to be effective. "It is clear that what is going to determine the course of HIV disease happens usually within the first few weeks of infection, from the burst of viremia and dissemination, to the seeding and destruction of the all-important lymphoid tissue, to the establishment of a viral reservoir with a latent component," Fauci said. "I refer to this period as the window of vulnerability because it is critical to vaccine and therapeutics research. . . . We need to determine whether any treatment or vaccine can mitigate the early course of HIV and alter these events, which establish so rapidly."

With vaccine development still stymied, infection prevention will have to stem the tide of new cases if the full therapy goal is to ever be achieved. "To talk of one thing — be it abstinence, or condoms, or topical microbicides in and of themselves in a vacuum — won't work," he said. "[Prevention] needs to be done in a comprehensive approach that is tailored to the people at a given risk."

But few tools are available to prevent infection, with only small percentages of adults globally even having access to HIV tests and condoms. "HIV internationally and even domestically is taking on the face of a woman," Fauci told ICAAC attendees. "We must address women-specific problems. One of the ways to do that over the next 10 years is an accelerated program for the development and testing for topical microbicides which would empower women to take into their own hands whether they will or will not be infected."