Prevention experts discuss what might work to reduce HIV incidence

Focus on African Americans and MSM

In the extended HIV prevention plan by the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, there is renewed focus on expanding HIV testing and focusing on African Americans and the men who have sex with men (MSM) communities.1

The plan also calls for the CDC to address HIV transmission in prisons and to increase HIV screening in medical care settings.1

The plan's short-term goal is to reduce the number of new HIV infections in the United States by 5 percent a year, or at least by 10 percent through 2010. This is to be done with a focus on eliminating racial and ethnic disparities in new infections.1

Experts say this will be difficult because of existing barriers to getting prevention messages across to those most at risk of infection.

HIV prevention is a tough message, and it's hard to reach the populations who need to hear it, says Michael S. Saag, MD, professor of medicine at the University of Alabama at Birmingham and the director of the UAB Center for AIDS Research.

"There is distrust among people who are disenfranchised, and there's an incredible belief system among sero-negatives that this will not happen to them," Saag explains.

In a recent commentary about how to decrease the new HIV infection rate in the United States, experts suggested these main strategies:

  • Find more people infected with HIV and provide them with counseling and other preventive services.2
  • Provide behavioral interventions to people with HIV to help lower their risk behaviors. These interventions should focus on transmission-related risk behaviors, such as substance use, mental illness, health care access issues, etc.2
  • Increase the percentage of HIV-infected people who have access to health care and treatment.2
  • Focus prevention interventions on people who are at behavioral risk for HIV infection.2
  • Educate the public about HIV to reduce stigma and increase general knowledge about the disease.2

The most important prevention strategy is to get people who are infected tested and into treatment and care, Saag says.

There are several reasons why HIV prevention messages targeting people who already are infected will work, Saag says.

First, people who are HIV positive and are in treatment are already practicing a very important prevention strategy, he says.

"I'm basing that on the biological concept of if we theoretically identified every HIV positive person in the world and treated them to undetectable levels of virus, then there'd be no further transmission of HIV," Saag says.

Secondly, targeting HIV prevention interventions to people who already are infected is cost-efficient because this group is already receiving HIV services of some kind.

People who are HIV positive already are seeing doctors and clinics to receive their care, so they could be receiving continuous prevention messages and interventions during those visits.

"We need more money to do this," says Edward Hook, III, MD, a professor of medicine at the University of Alabama at Birmingham (UAB). Hook is a co-chair of the CDC/HRSA Advisory Committee on HIV & STD Prevention and Treatment (CHAC).

"We cannot allow new infections to continue to occur at the same time we're trying to optimize the management of the disease," Hook says.

The solution is further interagency collaboration and coordination, Hook suggests.

Collaboration is needed because the challenges to preventing new HIV infections cut across governmental boundaries and often include cultural and political barriers.

For example, research shows that condoms and interventions to increase condom use can reduce HIV transmission among young people at risk of becoming infected.

But changing the minds of people who believe that to teach prevention encourages sexual activity is a challenge, Hook says.

"The HIV epidemic and problems manifested by our epidemic are interwoven, and the challenges to controlling it are interwoven throughout national societies," Hook says. "We need to address it at that level, and we need it coordinated."

For instance, the federal-wide agencies need better integration with regard to goals, synergies, and cooperation, including HRSA and CDC, Hook says.

"And the U.S. Department of Education could be included," he adds. "What about having national HIV prevention as a national goal to protect America's youth?"

The nation might achieve a 5 percent reduction in new HIV infections per year if the U.S. would adopt an opt-out HIV testing policy, Saag says.

It's a realistic goal to use opt-out, standardized testing for HIV to find as many HIV positive individuals as possible, to get them into HIV care, and to reduce the transmission rate as a result, he says.

The challenge will be to increase funding to handle the influx of newly-identified positives.

Saag recently published an editorial which says the adoption of a policy of opt-out universal testing for HIV will increase the number of new HIV patients seeking care by at least 25 percent over the next few years.1

Existing HIV clinics do not have the capacity to absorb those people, Saag says.

"We need to assure they can get into care and that clinics have the capacity to take care of their patients," Saag says. "Clinics aren't there to give away care — we need to be paid for what we do, and we need to redouble efforts to have the money we need to operate."

The new 2010 extended plan includes a goal to make HIV testing routine, says Donna E. Sweet, MD, MACP, professor of medicine at the University of Kansas School of Medicine in Wichita, KS. Sweet also is a co-chair of CHAC.

"Success depends on both funding and providers buying into routine testing and truly trying to find the 250,000 to 300,000 people in this country who are infected but do not know it and who are almost certainly responsible for a very high percentage of new infections," Sweet says.

The CDC has made it a priority to test people for HIV as part of the prevention strategy.

"Getting people to learn their HIV status remains critical because it's one of our most effective ways for two reasons," Janssen says. "For one, people have to know their status to get into care, and, two, once people learn their HIV status, they protect their partners from getting infected."

National HIV prevention efforts have not been implemented at the level that's needed, Janssen notes.

"Two years ago there was a behavioral surveillance study of MSM that found about 20 percent of those men had made contact or been involved in an HIV intervention in the previous 12 months," Janssen says. "It was only 20 percent, so the reach of our HIV prevention interventions has been pretty low."

By contrast, some international HIV prevention efforts have reported an impact on 80 percent of the desired population, Janssen says.

"I don't know if that's true, but it's what people have reported internationally," he adds.

References

  1. HIV prevention strategic plan: Extended through 2010 (extended plan). Centers for Disease Control and Prevention. October, 2007; available at http://www.cdc.gov.
  2. Saag MS. Opt-out testing: Who can afford to take care of patients with newly diagnosed HIV infection? Clin Infect Dis. 2007;45(Suppl4):S261-2265.