June 5, 2018, will mark 37 years since the CDC reported five cases of Pneumocystis carinii pneumonia in gay men in Los Angeles.1 Two of them were dead. Reports of similar cases began coming in from other parts of the country. The epidemic of what would later be called HIV/AIDS had begun.
It is difficult to overstate the dread and panic that struck the public and many healthcare workers still unsure of how the virus was transmitted. The occupational infections that occurred at that time through needlesticks and blood exposures are exceedingly rare today, but some risk remains. It is well to remember that HIV was once a uniformly fatal condition. There are positive trends and highly effective viral suppression treatments, but HIV still is with us.
“We have close to 40,000 new HIV infections every year. HIV is often a fatal disease if it is not treated, and it continues to be a challenge to reduce the number of new infections every year,” said Jonathan Mermin, MD, MPH, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.
However, there also are encouraging signs, and more gains will be seen if routine HIV testing becomes the norm, he stressed.
“We’ve seen reductions in HIV incidence — the number of new infections — every year in the country over the past decade,” Mermin said at a recent CDC press conference. “And we’ve seen dramatic reductions in mortality among people with HIV due to very effective medicine that can now be taken once a day in most cases.”
The advent of pre-exposure prophylaxis also has reduced transmission, and antiretroviral therapy can dramatically reduce circulating virus.
According to a new CDC report2, in 2015 the estimated median time from HIV infection to diagnosis was three years. The CDC had estimated that in 2011 the time was three years and seven months. That may seem like little more than an incremental gain, but the CDC says there is the potential for great progress if the trend continues. For example, 85% of some 1 million people living with HIV in 2014 knew their HIV status. Knowledge of status translates to reduced transmission.
“About 40% of new HIV infections in this country are from people who don’t know they have HIV,” said Eugene McCray, MD, director of the CDC’s Division of HIV/AIDS Prevention. “We must close the gap in time from HIV infection to HIV diagnosis to end our nation’s epidemic.”
Healthcare providers should continue to emphasize the importance of testing, prevention, and treatment, McCray said at the press conference.
“A positive HIV test allows people living with HIV to start treatment that will help them live longer, healthier lives, and get the virus under control,” Mermin says. “Controlling HIV through viral suppression treatment is a top national priority. Among people who have achieved viral suppression, HIV is detectable only at very low levels in the blood or is undetectable with standard tests. In recent studies of thousands of couples where one partner has HIV and the other does not, there have been no sexually transmitted HIV infections when the HIV-positive partner was virally suppressed.”
Indeed, testing informs prevention options for a broader group of people who do not have HIV but may be at risk for infection.
“CDC recommends all people aged 13-64 be tested for HIV at least once in their lifetime, and people at higher risk for HIV at least annually,” Mermin said. “Healthcare providers may also find it beneficial to test some people more frequently than that.”
For the new report, the CDC analyzed data gleaned from the National HIV Behavioral Surveillance System to understand HIV testing rates among people at particularly high risk for HIV. Those include gay and bisexual men, injection drug users, and heterosexuals at increased risk for HIV. Concerning that last group, heterosexual sex is the primary route of transmission of HIV for women.
“Although HIV testing is up among these risk groups, our report found we still need to test more people and test more often,” Mermin said. “Those reporting they did not have a recent HIV test were almost one-third gay and bisexual men, more than two in five people who inject drugs, and more than one in two heterosexuals at risk for HIV.”
In what Mermin described as a “missed opportunity,” the CDC study found that seven in 10 people in an HIV risk group had seen a healthcare provider in the last year but were not tested. “Without increased testing, many people living with HIV may not know they have it for years,” he said.
For example, about 25% of those diagnosed with HIV in 2015 had beeen infected with the virus for at least seven years, he said.
Overall, the CDC found that the estimated median time from HIV infection to diagnosis was three years in 2015. The estimated time from HIV infection to diagnosis for heterosexual men was a median of five years — twice as long as heterosexual women, Mermin said.
“The median was three years for gay and bisexual men,” he said.
“The estimated timing from HIV infection to diagnosis ranged from a median of four years for Asian-Americans to two years for white Americans. The median was about three years for African-Americans and Latinos.”
From a socioeconomic view, HIV remains a quintessential example of “persistent” public health disparities, he said. “African-Americans are eight times more likely and Latinos are 10 times more likely to have HIV infections than white Americans,” Mermin said.
“It can be geographically distributed. The southern part of the United States has higher HIV burden than any other region. And certain age groups and sexes, as well as gay and bisexual men. So, we have seen these disparities.”
Investment in testing in these hard-hit groups spells prevention and money saved that otherwise would have gone to treatment and other costs. A CDC economic analysis showed that for every dollar spent on testing, a minimum of two dollars is saved by the healthcare system, he said.
- CDC. Pneumocystis pneumonia — Los Angeles. MMWR 1981;30:250–252.
- CDC. HIV Testing. Vital Signs Nov. 28, 2017. Available at: http://bit.ly/2zNEolj. Accessed Dec. 6, 2017.