Over the past few years there has been a great deal of discussion―though some might cynically describe it as sloganeering―about bringing the number of new cases of HIV in the United States down to zero. But the announcement last month that the START (Strategic Timing of AntiRetroviral Treatment) trial definitively shows that early treatment for HIV extends life expectancy and reduces HIV-related illness over a lifetime further solidifies the role of early treatment as an important tool in the anti-HIV arsenal.
Early treatment for HIV has been the standard of care in the United States since 2011, when the results of a study of nearly 1800 sero-discordant couples living in nine countries showed that early HIV treatment dramatically reduced incidences of HIV transmission within the couple.
Even so, the numbers of new HIV infections in the United States still have not budged from approximately 50,000 per year. That's because treatment as prevention does not work in a vacuum.
Exciting medical innovations such as early HIV treatment, which makes transmission of the virus nearly impossible, must be combined with effective universal screening for HIV. Only that will bring us tantalizing closer―at least domestically―to zero new HIV infections. Approximately 14 percent of those who are living with HIV in the United States (approximately 1.2 million people) are unaware of their status. We cannot treat them if they are not seeking care for a disease they do not know they have. Although the United States Preventive Services Task Force and the Centers for Disease Control both recommend HIV screening for all adults, only 45 percent of adults report ever having been tested for HIV.
It's interesting to remember that one year after early HIV treatment became the standard of care, the FDA approved Pre-Exposure Prophylaxis (PrEP), a daily anti-viral pill, as a prevention option for those who are vulnerable to HIV infection after a large randomized study among men who have sex with men showed that PrEP reduced the rate of HIV infection by 92 percent among men who took the drug as prescribed. Despite its effectiveness, most of those who could benefit from it don't know about it, and most clinicians either aren't aware of the efficacy of PrEP or won't prescribe it as a prevention tool.
It is clear that universal screening coupled with prescriptive strategies like early treatment for HIV and PrEP hold great potential to reduce the transmission of HIV when done effectively. The Massachusetts experience is instructive in this regard. In 2001, the state expanded Medicaid coverage for low-income individuals living with HIV. Before this change, low-income individuals with HIV who did not have health insurance had to wait until their disease had progressed to a diagnosis of AIDS before becoming eligible for free health insurance. Additionally, the state's 2006 health care reform law dramatically expanded access to health care insurance―and health care―to everyone else in the state. As a result, there are few structural barriers to health care in Massachusetts for anyone living with HIV, and among those living with HIV, 70 percent of them have a non-detectable viral load. This far surpasses the national average of just 25 percent of those living with HIV having achieved a non-detectable viral load.
The national expansion of health care insurance under the Affordable Care Act will make it much easier for those living with HIV, particularly low-income individuals, to access health care and early treatment for HIV, along with PrEP. But if clinicians aren't aware of the benefits of PrEP and early HIV treatment, the potential of these medical strategies will never be met. And in states where there has not been an expansion of Medicaid, many at high risk will still find effective care out of reach.
Clearly, getting to zero is going to take systematic training and education for clinicians.
But if we have learned anything over the 30-year course of the AIDS epidemic, it is that we would be foolish to put all of our HIV prevention eggs in the treatment basket. It is essential that medical interventions like early treatment and PrEP are combined with robust and aggressive efforts to create health care settings that are affirmative and welcoming for LGBT patients and others who are vulnerable to HIV infection.
Rates of HIV infection are climbing among young Black men who have sex with men, and the presence of HIV is highest among transgender women of all groups of adults. It is no coincidence that these are some of the very people who report the most negative experiences in health care settings, ranging from disrespectful treatment by waiting area staff to dismissive treatment by clinicians. Last year, the National LGBT Health Education Center conducted focus groups with LGBT patients across the South. Many participants reported having experienced humiliating and embarrassing treatment by staff at health care centers. Notably, the results were not dissimilar to those found with focus groups held with LGBT individuals in Massachusetts.
If potentially HIV-positive patients are walking out the door based on how they treated by clerical staff―before they get tested or ever get in to see a clinician―they are losing the option of not just learning about their status, but also the opportunity for early treatment. Training health care staff at every level about how to communicate effectively and respectfully with LGBT patients isn't just a feel-good exercise. Those of us who are doctors and nurses have a covenant to provide equitable care for all. But unless we make this a reality by making sure that we offer appropriate care with follow up and assure a welcoming and inclusive experience from the time someone enters our waiting rooms and exam areas throughout their visit, we will never get to zero new HIV infections.