By Rebecca Bowers

EXECUTIVE SUMMARY

About 80% of new HIV transmissions can be linked to people whose infection is undiagnosed or is not currently treated, according to findings from a just-published analysis.

  • Public health officials are now moving on this information to get more people tested and into care as part of the new federal initiative to end the HIV epidemic.
  • The initiative entails four key strategies: diagnosing HIV as early as possible after infection, treating HIV rapidly and effectively to achieve sustained viral suppression, protecting people at risk for HIV using prevention approaches such as pre-exposure prophylaxis, and responding rapidly to growing HIV clusters to stop new infections.

About 80% of new HIV transmissions can be linked to people whose infection is undiagnosed or not currently treated, according to findings from a just-published analysis.1 With this information in hand, public health officials are moving to get more people tested and in care.

Admiral Brett Giroir, MD, assistant secretary for health at the U.S. Department of Health and Human Services, says there is an “unprecedented opportunity” now to stop the HIV epidemic in America. An effort must be made to close gaps in HIV prevention and care, Giroir said in a press statement.

Getting more people tested and into HIV care is a critical part of the new federal initiative, “Ending the HIV Epidemic — A Plan for America,” which was launched recently to end the HIV epidemic. Four key components comprise the initiative: diagnosing HIV as early as possible, treating infections quickly to achieve sustained viral suppression, protecting those at risk for HIV with prevention approaches such as pre-exposure prophylaxis (PrEP), and responding quickly to growing HIV clusters to halt new infections.

Although tools are available to end the HIV epidemic, they are useful only if put into practice, says Jonathan Mermin, MD, MPH, director of the Centers for Disease Control and Prevention (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

“This is why it’s vital to bring testing and treatment to everyone with HIV — and to empower them to take control of their lives and change the course of the epidemic,” said Mermin in a press statement.

Get Going on Testing, Treatment

Reducing new infections is imperative if the HIV epidemic is to be stopped. Efforts should be aimed at increasing the proportion of people who are aware of their HIV status, states the new report.

Be sure that all patients ages 13-64 have been tested at least once for HIV, says the CDC. Those at high risk should be tested at least annually, with sexually active gay and bisexual men benefitting from more frequent testing (every three to six months).

Be sure to help those with HIV get care. It is estimated that the 23% of people with HIV who have received a diagnosis but who are not receiving HIV care account for 43% of all HIV transmissions. According to the CDC, taking antiretroviral therapy, or ART, not only helps to achieve and maintain an undetectable viral load for patients with HIV, it also aids in preventing transmission of the virus to others.

Research indicates that treatment as prevention is very effective for preventing transmission of HIV through sexual contact. Strong evidence from recent studies demonstrates that such treatment works; in three studies, data suggested that no linked HIV transmissions were observed between partners with mixed HIV status when the partner with HIV was virally suppressed.2-5 More research is necessary to determine how well viral suppression prevents transmission of the virus by other routes.

For patients with HIV, be sure to stress the importance of taking medicine to maintain viral suppression. Data indicate that the 11% of people with HIV who were receiving care but were not virally suppressed account for 20% of all HIV transmissions.1 When talking about patients continuing treatment, the CDC advises that it may be helpful to share information about research with patients, and then ask open-ended questions to encourage further conversation. Consider using the following approaches suggested by the CDC:

  • We have evidence in hand of mixed-HIV-status couples who engaged in thousands of unprotected sex acts while the partner with HIV was taking ART to achieve viral suppression. There was no evidence that a single HIV-negative person got HIV from their sexual partner with a viral load that was undetectable. What does this information mean to you?
  • To maximally reduce the risk of sexual transmission of HIV, you must achieve and then maintain an undetectable viral load. How do you feel about that?
  • Good news: Your viral load continues to be undetectable. Tell me the methods you are using to prevent other STDs.6

Don’t Forget PrEP, PEP, and Condoms

Prevention tools like condoms and PrEP are important for people who are at risk for HIV. Discuss the fact that correct use of male condoms and other barriers, such as female condoms and dental dams, can lower the risk of sexually transmitted infections, including HIV. Explain that, for the highest protective effect, condoms must be used correctly and consistently throughout the entire sex act, from the start of sexual contact to after ejaculation.

PrEP is a method of prevention used by people who are HIV-negative and at high risk for exposure to HIV through sexual contact or injection drug use. The Food and Drug Administration-approved PrEP medication is oral tenofovir disoproxil fumarate and emtricitabine (TDF-FTC), which is available as a fixed-dose combination in a tablet (Truvada). Explain to patients that when a person is exposed to HIV through sexual contact or injection drug use, these medicines can work to keep the virus from establishing an infection. Guidance calls for patients who take PrEP to commit to taking the drug every day, as well as to attend follow-up visits with their healthcare provider every three months.

Post-exposure prophylaxis, or PEP, is the use of antiretroviral drugs for people who are HIV-negative after a single high-risk exposure. This prevention method must be started as soon as possible to be effective; guidance calls for initiation within 72 hours of a possible exposure, with continued dosing for four weeks. PEP is recommended for potential exposures through sexual contact or injection drug use, and should be provided only for infrequent exposures. For patients who engage in behaviors that result in frequent, recurrent exposures, clinicians should advise the use of PrEP.

Get your patients ready to use PrEP and PEP with questions such as these:

  • What do you do when a condom breaks?
  • What works for you when you talk with partners about HIV prevention medicines, like PrEP? What doesn’t work?
  • When you party, are injecting drugs part of the action? If so, are you sharing needles or drug preparation equipment with others?

REFERENCES

  1. Li Z, Purcell DW, Sansom SL, et al. Vital Signs: HIV transmission along the continuum of care United States, 2016. MMWR Morb Mortal Wkly Rep 2019;68:267-272.
  2. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493-505.
  3. Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med 2016;375:830-839.
  4. Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016;316:171-181.
  5. Bavinton B, Grinsztejh B, Phanuphak N, et al. HIV treatment prevents HIV transmission in male serodiscordant couples in Australia, Thailand and Brazil. Presented at the 9th IAS Conference on HIV Science (IAS 2017). Paris; July 2017.
  6. Centers for Disease Control and Prevention. HIV transmission prevention: Information for health care providers. Available at: https://bit.ly/2D0FsUG. Accessed May 28, 2019.