HIV prevention goal still elusive
30 years and 1 million infected
Researchers who have closely studied the United States' national HIV/AIDS prevention strategy as it has developed over the past three decades have concluded that it has been underfunded, and it's very difficult to implement.1
"Many presidential administrations have tried to put together a plan," says Baligh Yehia, MD, a post-doctoral fellow in the division of infectious diseases at the University of Pennsylvania in Philadelphia, PA. Yehia also is a student at the Woodrow Wilson School of Public Health and International Affairs at Princeton University in Princeton, NJ.
"What people have learned over the years is that you cannot have too many goals," Yehia says. "When you look at recommendations from the Reagan commission and the Clinton plan, and now Obama's, you can see they are becoming more and more focused."
Specifically, the Obama HIV/AIDS strategy calls for reducing the annual number of new infections by 25% by 2015. This would reduce new infections from the current estimate of 56,300 to 42,225. The plan also has the goal of reducing the HIV transmission rate by 30% and increasing the percentage of people living with HIV who know their serostatus from 79% to 90%. The strategy calls for increasing the proportion of newly diagnosed patients linked to clinical care within three months from 65% to 85%, as well as increasing the proportion of HIV patients in continuous care.1
Like many public health prevention expenses, the estimated $15 billion in upfront spending on HIV prevention and care would have a greater return on investment, estimated to be about $18 billion.1
"There are many important challenges, and those challenges are formidable," Yehia says. "The most important one is to secure new federal funds for this strategy."
For HIV patients and public health, the stakes are high given current trends.
"We know a lot of people today are linked to care after they have AIDS," Yehia says.
An estimated 45% of patients develop AIDS within three years of receiving their HIV diagnosis, a dire statistic that points to failures in HIV screening and linkage to care and treatment.1
By the time HIV-infected patients are tested and placed in care, many are very sick, requiring more intensive and expensive health care. And they likely have transmitted the virus to other people. Alternatively, if they had been identified far earlier in their infection, their health could have been preserved, and the public health would have benefited from a dramatically reduced risk of HIV transmission to others.
"This is something we need to start thinking about," Yehia notes. "When we find someone infected with HIV and put them on antiretroviral therapy, this helps control the disease and prevents spreading infection to other people."
One of the low-hanging fruit in using treatment as a public health prevention strategy would be the 9,000-plus Americans on the AIDS Drug Assistance Program (ADAP) waiting lists in 11 states. These patients already have been identified as HIV positive and in need of antiretroviral therapy (ART). Yet, their medical care is jeopardized by inadequate federal and state funding, he says.
"We need funding," Yehia says. "There are certain states that don't have enough funds to pay for people who know they have HIV, and that's not including the 25% to 28% of people who don't know they're infected."
These statistics and the waiting lists are a sign that access to HIV treatment is in jeopardy and disparities are increasing.
"Obviously, as a nation we have to weigh our national priorities, and HIV is definitely important, as are education and other things," Yehia says. "But we have to use our money wisely, and if there is an area that would be beneficial, it would be to make sure everyone has access to HIV medicine because that has a big impact on patients and the community."
If the latest HIV/AIDS prevention strategy does not reach its goals of decreasing new infections, eliminating disparities, and increasing access to care, then it will not be the first prevention strategy to fail. As the evaluation of the nation's succession of HIV/AIDS strategies shows, previous administrations also failed to reach many of their goals.1
Under the Bush administration, the Centers for Disease Control and Prevention (CDC) revised HIV testing recommendations to increase HIV screening in all health care settings, but it has encountered pragmatic and social barriers to full implementation.1
The lack of adequate public health funding coupled with systemic socioeconomic issues make it extremely difficult for the national HIV/AIDS plan to succeed.
"It's very hard to decrease disparities in HIV care if you solely focus on race/ethnicity and gender," Yehia says.
Improved health literacy rates, needle exchanges, economic disparities, lifestyle and housing issues, and other social challenges also need to be addressed, he adds.
"In the national strategy, they focus on Latinos, blacks, and men who have sex with men, and those are groups that we can measure," Yehia explains.
"But to reduce disparities in those groups you have to look beyond that: are the folks getting incarcerated more? How do you break that cycle in the community where folks are not always in jail? How do you provide some wealth for a family where the mother has to exchange sex for food or money?" he adds. "It goes deeper than just race."
- Yehia B, Frank I. Battling AIDS in America: an evaluation of the national HIV/AIDS strategy. AJPH. 2011;July 21:[Epub ahead of print.]