Research shows many young Americans are unaware they are HIV infected
Young people missing in continuum of care as well, report indicates
Statement of Financial Disclosure: Consulting Editor Robert A. Hatcher, MD, MPH, Author Rebecca Bowers, and Executive Editor Joy Dickinson report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Sharon Schnare (Nurse Reviewer) discloses that she is a retained consultant and a speaker for Barr Laboratories, Berlex, and Organon; she is a consultant for 3M Pharmaceuticals; and she is a speaker for FEI Women’s Health, Ortho-McNeil Pharmaceuticals, and Wyeth-Ayerst Pharmaceuticals.
A recent analysis of data from the National HIV Surveillance System indicates that Americans under age 45 who are infected with the HIV virus are much less likely than their older peers to know they are infected or to be receiving proper care.1
About 50,000 new HIV infections develop in the United States each year.2 To achieve effective treatment, often referred to as the HIV care continuum or cascade, patients must undergo testing, be linked to care, stay within care, initiate antiretroviral therapy (ART), and achieve an undetectable viral load. Of the estimated more than 1.1 million persons living with HIV in 2009 (the most current data available for the report), nearly 81.9% had been diagnosed, 65.8% were linked to car, and 36.7% were retained in care, 32.7% were prescribed ART, and 25.3% had a suppressed viral load.1
To compile the report, analysts looked at the most current data from the Centers for Disease Control and Prevention’s (CDC) National HIV Surveillance System to determine the number of persons living with HIV who are aware and unaware of their infection. They also used information from the Medical Monitoring Project, a surveillance system of persons receiving HIV care, to estimate the percentages of persons retained in care, prescribed antiretroviral therapy, and with suppressed viral load.
The report’s data suggests that lower percentages of people ages 25-44 received regular care, were prescribed drug therapy and had a suppressed viral load, compared with those ages 55-64. For example, 28% of young adults with HIV were receiving treatment, compared with 46% of those ages 55-64.1
"Our study finds that, across all populations, far too few Americans with HIV receive the care they need to stay healthy and reduce risk of transmission," says Irene Hall, PhD, lead author of the report and CDC epidemiologist. "Gaps in care are the largest among African Americans and young people."
Moving forward, improving care for all HIV-infected people will be critical to achieving the goal of an AIDS-free generation in America, says Hall. At the CDC, public health officials are putting what is termed "High-Impact Prevention" into motion, directing resources to close gaps in care.
Testing efforts expanded
The agency is working to expand testing efforts to ensure people living with HIV are diagnosed and linked to care, says Hall. "For example, CDC is funding community-based organizations throughout the nation to reach young gay and bisexual men who account for the vast majority of new HIV infections among youth with testing and other critical prevention services," she notes. "Additionally, we are working to develop and implement behavior-change programs to help youth, African Americans, and others reduce risk behaviors."
The CDC also is prioritizing services for those living with HIV, including efforts to improve retention in care, adds Hall. However, the agency can’t do it alone, she notes. Health departments, health care providers, and community-based organizations play critical roles as well, states Hall.
Find what works
The CDC is supporting demonstration projects in 12 heavily affected cities that represent 44% of the total U.S. AIDS cases. The 12 grantees include state and territorial health departments (Georgia, Florida, Maryland, Texas, Puerto Rico, and District of Columbia), and directly-funded local health departments (Los Angeles County, San Francisco, Chicago, Houston, New York City, and Philadelphia). The CDC funding allows local health departments to identify and put in motion practices that are likely to have the greatest impact in their communities, based on the profile of their local epidemic and an assessment of the gaps in current HIV prevention programs. While the exact combination of approaches varies by area, all of the projects emphasize intensifying HIV prevention and testing for individuals at greatest risk; prioritizing prevention and linkage to and retention in care for people living with HIV; and directing efforts to the populations with the highest HIV burden.
For example, in Houston, CDC funding has allowed health officials to identify five neighborhoods with particularly high rates of HIV and sexually transmitted infections (STIs). The Houston Department of Health and Human Services has launched the Strategic AIDS/HIV Focused Emergency Response, which targets the five neighborhoods with intensified HIV testing, services for the partners of those infected, educational workshops, condom education and distribution, and social marketing efforts.
In Los Angeles, CDC funding has enabled analysis of integrated HIV and STI surveillance data to identify five "hot spots" where about 80% of all HIV, syphilis, and gonorrhea cases in Los Angeles County have been reported. By using this analysis, public health officials have been able to develop sophisticated modeling to determine the underlying factors that increase HIV risk, such as high STD rates, homelessness, poverty, substance addiction, and mental illness. The county is working to deliver more integrated health services to those living with and at risk for HIV using this targeted information.
In an invited commentary to the report, University of California, San Francisco School of Medicine’s Katerina Christopoulos, MD, MPH, assistant adjunct professor, and Diane Havlir, MD, professor, look at the state of the cascade of HIV care.3 Such focus is necessary; in 2011, data indicated that only about a quarter of individuals living with HIV were successfully receiving HIV treatment.4
"The sobering numbers of those missing out on effective treatment because they did not know they were infected and those who knew their status but did not seek care spurred collaboration between the HIV treatment and prevention movements, two areas with different funding streams that often operated independently of one another," they state. "Already the HIV community has mobilized to further develop and study interventions that address bottlenecks in the cascade."
Promising approaches needing study include home testing to reach disenfranchised populations, cellular technology to promote ART adherence, and contingency management for virologic suppression.5,6
The lessons learned from the HIV cascade may apply to other infectious diseases, such as hepatitis C virus infection, and chronic diseases, such as diabetes, hypertension, and hyperlipidemia, the authors note.
"Partnering with other medical specialists to find points of similarity and difference in care cascades is crucial, because what ultimately matters is not just retention in HIV care but all medical care," they state.
- Hall H, Frazier EL, Rhodes P, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med 2013; doi:10.1001/jamainternmed.2013.6841.
- Centers for Disease Control and Prevention. New HIV infections in the United States. Fact sheet. Accessed at http://1.usa.gov/T873CS.
- Christopoulos KA, Havlir DV. Overcoming the human immunodeficiency virus obstacle course. JAMA Intern Med 2013; doi: 10.1001/jamainternmed.2013.7943.
- Centers for Disease Control and Prevention (CDC). Vital signs: HIV prevention through care and treatment — United States. MMWR 2011; 60(47):1,618-1,623.
- Lester RT, Ritvo P, Mills EJ, et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 2010; 376(9755):1,838-1,845.
- 6. HPTN 065. TLC-Plus: a study to evaluate the feasibility of an enhanced test, link to care, plus treat approach for HIV prevention in the United States. Accessed at http://bit.ly/aQOpEB.