Since the beginning of the HIV epidemic in the United States, significant progress has been made to reduce the rate of new infections, particularly through the development of an effective prescription medication that protects against HIV. However, significant barriers remain, both in terms of access and accurate risk assessment. For example, though black men who have sex with men (MSM) are disproportionately burdened by HIV compared to their white MSM counterparts, they are less likely to access PrEP services, due to structural factors that influence their ability to access (i.e. lack of insurance coverage) and cultural factors (i.e. stigma of PrEP use, HIV infection, or sexual practices) that contribute to a lower self-perceived risk of HIV infection. Policymakers, researchers, and clinicians play a vital role in ensuring the delivery of timely, culturally competent care, leveraging existing data infrastructure to track populations at risk, and educating the public to reduce HIV stigma and discrimination.
With the advent of the COVID-19 pandemic, the United States is further challenged in the mission to end the HIV epidemic that has claimed more than 700,000 American lives while also prioritizing an effective COVID-19 response. Specifically, the United States must ensure that those at high-risk are continuing to receive access to appropriate preventative measures, individuals living with HIV are adhering to their antiretroviral therapy, and policymakers are making appropriate adjustments to HIV treatment and practice protocols in the face of a co-occurring global pandemic. These actions will require coordinated efforts between a wide variety of stakeholders, including policymakers, the federal government, state and local health departments, researchers, and the public, a number of who are equally involved in the response in addressing both viruses.
On February 5, 2019, the Trump Administration announced their plan for a bold new initiative, implemented by the Department of Health and Human Services (HHS), to eliminate the HIV epidemic by 2030. Ending the HIV Epidemic: A Plan for America (EHE) builds upon four distinct pillars to combat the epidemic:
- diagnose all individuals with HIV as early as possible after infection;
- treat the infection rapidly and effectively after diagnosis, achieving sustained viral suppression;
- protect individuals at risk for HIV using proven prevention approaches; and
- respond rapidly to detect and respond to growing HIV clusters and prevent new HIV infections.
HHS introduced the initiative in localities experiencing more than 50% of new HIV infections nationwide. This includes 48 state counties, the two cities of Washington, D.C., and San Juan, Puerto Rico, along with seven southern states with significant rural HIV burden. Though researchers have made significant progress across the four pillars, gaps in the research persist. To address these gaps and accomplish the goal of ending the epidemic by 2030, multi-stakeholder engagement is needed. This two-part blog series will focus on issues relating to three of the four pillars. In this post, I will outline the HIV landscape and the Protect pillar and in the second post, I’ll focus on the Diagnose and Treat pillars.
Prevention Measures Have Reduced the Rate of New Infections, but Access Remains an Issue
The first cases of what we now know as AIDS were diagnosed in June 1981. Since its discovery, more than 700,000 people have died in the United States due to AIDS-related conditions. Currently, approximately 1.1 million individuals are living with HIV in the US, with 15 percent of individuals being unaware of their infection. While everyone is at risk of contracting the virus, HIV continues to disproportionately affect certain populations in the United States, particularly gay and bisexual men and racial and ethnic minorities. Though innovative preventative measures and an increased focus on getting individuals living with HIV on antiretroviral therapy have reduced the rate of new infections, the number of new infections has remained stable at 38,000 a year since 2013, with many of these infections being preventable. Thus, researchers must look towards current and innovative preventative measures proven to reduce infections. In 2012, the Food and Drug Administration approved Truvada for Pre-Exposure Prophylaxis (PrEP) for use offering the potential to revolutionize treatment and prevention for HIV. The drug is a once-daily oral medication that HIV-negative individuals can take prior to coming in contact with HIV which inhibits the virus’ ability to establish infection in the body. HHS has emphasized the use of PrEP, particularly among vulnerable populations, as an effective mechanism to prevent the transmission of HIV and end the epidemic, in addition to traditional preventative measures.
Despite prevention initiatives being the most effective way to control the epidemic, of the $34.8 billion of federal funding dollars devoted to HIV in FY 2019, only $0.9 were allocated for prevention. Though PrEP uptake is cited as a vital component of HHS’ initiatives to prevent transmission, 82 percent of individuals who could benefit from PrEP usage do not have access to it, particularly young people and racial and ethnic minorities. In addition, sexually transmitted diseases (STD) are at an all-time high in the United States. Research shows that having an STD increases your risk in contracting HIV, and given that STDs disproportionately impact those already at risk of contracting HIV, this further increases their risk. Finally, though a number of federal agencies have added sexual orientation and gender identity (SO/GI) as required elements in EHRs, many LGBT individuals do not choose to self-identify due to stigma and discrimination. This significantly limits the ability to provide preventative care to LGBT individuals at risk for certain health conditions, including HIV.
HSR Can Contribute to Culturally Competent Care, Enhanced Data Use & Screening
In order to reduce new infections, researchers should assist policymakers in developing a multi-faceted approach to both identify individuals most at risk as well as providing individuals the appropriate resources to prevent infection. Reducing HIV-related health disparities must be a key focus in ending the epidemic in the United States, particularly amongst racial and ethnic minorities and gay and bisexual men. Local and state health departments and clinical professionals should consider enhancing partnerships between community-based organizations, sister government agencies (e.g., Medicaid) and other trusted stakeholders to educate communities through culturally competent care on high-risk sex behaviors, the hazards of non-sterile injection drug use, and effective preventative measures such as PrEP in order to effectively reduce infections amongst these historically marginalized communities.
In addition, state agencies should be strategic when constructing their data use agreements (DUAs), particularly between public health and Medicaid, in order to enable the sharing of broader data sets (state corrections, housing data, social services, etc.) to facilitate stronger surveillance and monitoring systems at the state and local level. Effective prevention interventions can only be successful with an understanding of the complex factors that lead to the transmission of the virus. Strategically analyzing the data in surveillance systems will allow government and public health officials to allocate resources to prevention interventions that match the needs of their jurisdiction.
Given the heightened risk for contracting HIV when diagnosed with a co-occurring STD, physicians and researchers should consider implementing strategies to assess individuals with recent STD diagnoses for a PrEP prescription. Notably, though PrEP is proven as an effective preventative measure, researchers have also cited a need for a set of updated nationally recognized PrEP quality practice measures, utilizing the CDC’s 2017 Clinical Practice Guidelines as a benchmark. In addition, more research is needed on the impacts of coverage decisions for PrEP ancillary services (lab services and other clinical work) as a barrier to continued PrEP utilization. Finally, physicians could consider innovative strategies such as Post-Exposure Prophylaxis (PEP) to PrEP transitions, PrEP on-demand, and TelePrEP, to increase access and adherence to PrEP medication.
Moving forward, researchers and health authorities should continue to prioritize preventing new infections and target initiatives toward the communities that are disproportionately affected by the epidemic. For individuals who are currently living with HIV, federal stakeholders can focus on strategies aimed at increasing individual’s knowledge of HIV status, increasing linkage to HIV care, and retaining individuals in care to achieve viral suppression. These efforts, and others, will be addressed in the next post in this series focusing on the Diagnose and Treat pillars of the Ending the HIV Epidemic: A Plan for America.
AcademyHealth recently executed a one-year project that sought to improve Medicaid availability and delivery of the PrEP intervention package, particularly recommended clinical monitoring and follow-up services such as STD screening and treatment. Guided by a Steering Committee of diverse stakeholders, the project focused on assessing and addressing structural, operational, financial, and knowledge barriers regarding PrEP intervention services among providers, payers, and public health leaders.