Universal HIV Screening Encouraged by Dr. Marcus Conant

SEOUL, SOUTH KOREA – It is time for a new strategy aimed at preventing HIV infection in the United States, an AIDS expert said at the World Congress of Dermatology.

This strategy ought to be built around universal testing, treatment starting at the moment of diagnosis, and public health monitoring of compliance, said Dr. Marcus Conant, a dermatologist at the University of California, San Francisco, who in 1981 was among the first physicians to identify AIDS and was a cofounder of the San Francisco AIDS Foundation.

The current prevention strategy has been in place since the 1980s. It is based on education about the use of condoms and other safe sex practices, along with voluntary testing for HIV – and it is simply not working.

Roughly 58,000 new cases of HIV have occurred annually in the United States over the past 15 years, with no drop-off trend. It is a prevention strategy that was developed when the epidemic was centered in the gay community. Now the epidemic is moving toward black and Hispanic individuals, who are poorly educated about HIV risk and don’t ask to be tested for HIV because they do not realize they are at risk.

"What was true 30 years ago is no longer true today, and yet we're caught in this time warp where we're not changing how we approach the disease. My message really is what we were doing 30 years ago was applicable then, but it's not applicable today," Dr. Conant said.

Today, one-third of HIV-positive individuals do not know they are infected. Another one-third are aware they are HIV positive but are not on highly active antiretroviral therapy (HAART), most often because they lack health insurance coverage. But it is the remaining third of HIV-infected individuals – those on drug therapy – who are of greatest concern, because only 19% of them have an undetectable viral load. The other 81% on drugs are potentially transmitting partially or totally resistant virus to their sex partners.

"It begs the question of how many years will it take until the virus in America is totally resistant to all of the drugs we currently have. We saw this happen with penicillin and Staphylococcus aureus. We've been there. We know this is going to happen. And yet we're sitting here watching it happen and doing very little about it," Dr. Conant said.

"With 58,000 newly infected individuals per year, and with only 19% of those being treated having undetectable viral loads, we are sitting on a prescription for disaster. Resistance is going to become a huge problem in the next decade," he warned.

Recent studies have demonstrated that early initiation of HAART results in longer survival, fewer side effects, and better compliance. Plus, patients having an undetectable viral load are at lower risk of transmitting the disease to a sex partner. That is why Dr. Conant believes that stopping the HIV epidemic requires testing everyone, treating everyone who is infected, and monitoring all infected individuals in order to strongly encourage maintaining an undetectable viral load.

Everybody, regardless of age, who has blood drawn for any reason – a routine physical exam, pregnancy, induction into the military – should have that blood sample tested for HIV, he said. Pooled polymerase chain reaction testing of low-risk groups, such as women, could be done to make universal testing more economical.

In any case, the pharmaceutical industry could easily foot the bill for universal testing. By identifying the one-third of HIV-positive individuals who do not know they’re infected, the drug companies stand to make a fortune in increased sales of HAART, according to Dr. Conant.

Current U.S. guidelines call for initiating HAART in HIV-positive patients with a CD4 count below 350 cells/mm³. But it makes more sense to begin treatment as soon as someone is found to be HIV positive, even though this practice isn't supported by randomized controlled trial evidence. It's better for the patient's health, and it's better for society because effective therapy stops transmission of the disease, he said.

All HIV-positive individuals could be logged into a computer-based tracking system so local public health departments could identify those who don't have an undetectable viral load and visit them to find out why, Dr. Conant proposed.

He said he had no relevant financial disclosures.

SEOUL, SOUTH KOREA – It is time for a new strategy aimed at preventing HIV infection in the United States, an AIDS expert said at the World Congress of Dermatology.

This strategy ought to be built around universal testing, treatment starting at the moment of diagnosis, and public health monitoring of compliance, said Dr. Marcus Conant, a dermatologist at the University of California, San Francisco, who in 1981 was among the first physicians to identify AIDS and was a cofounder of the San Francisco AIDS Foundation.

The current prevention strategy has been in place since the 1980s. It is based on education about the use of condoms and other safe sex practices, along with voluntary testing for HIV – and it is simply not working.

Roughly 58,000 new cases of HIV have occurred annually in the United States over the past 15 years, with no drop-off trend. It is a prevention strategy that was developed when the epidemic was centered in the gay community. Now the epidemic is moving toward black and Hispanic individuals, who are poorly educated about HIV risk and don’t ask to be tested for HIV because they do not realize they are at risk.

"What was true 30 years ago is no longer true today, and yet we're caught in this time warp where we're not changing how we approach the disease. My message really is what we were doing 30 years ago was applicable then, but it's not applicable today," Dr. Conant said.

Today, one-third of HIV-positive individuals do not know they are infected. Another one-third are aware they are HIV positive but are not on highly active antiretroviral therapy (HAART), most often because they lack health insurance coverage. But it is the remaining third of HIV-infected individuals – those on drug therapy – who are of greatest concern, because only 19% of them have an undetectable viral load. The other 81% on drugs are potentially transmitting partially or totally resistant virus to their sex partners.

"It begs the question of how many years will it take until the virus in America is totally resistant to all of the drugs we currently have. We saw this happen with penicillin and Staphylococcus aureus. We've been there. We know this is going to happen. And yet we're sitting here watching it happen and doing very little about it," Dr. Conant said.

"With 58,000 newly infected individuals per year, and with only 19% of those being treated having undetectable viral loads, we are sitting on a prescription for disaster. Resistance is going to become a huge problem in the next decade," he warned.

Recent studies have demonstrated that early initiation of HAART results in longer survival, fewer side effects, and better compliance. Plus, patients having an undetectable viral load are at lower risk of transmitting the disease to a sex partner. That is why Dr. Conant believes that stopping the HIV epidemic requires testing everyone, treating everyone who is infected, and monitoring all infected individuals in order to strongly encourage maintaining an undetectable viral load.

Everybody, regardless of age, who has blood drawn for any reason – a routine physical exam, pregnancy, induction into the military – should have that blood sample tested for HIV, he said. Pooled polymerase chain reaction testing of low-risk groups, such as women, could be done to make universal testing more economical.

In any case, the pharmaceutical industry could easily foot the bill for universal testing. By identifying the one-third of HIV-positive individuals who do not know they’re infected, the drug companies stand to make a fortune in increased sales of HAART, according to Dr. Conant.

Current U.S. guidelines call for initiating HAART in HIV-positive patients with a CD4 count below 350 cells/mm³. But it makes more sense to begin treatment as soon as someone is found to be HIV positive, even though this practice isn't supported by randomized controlled trial evidence. It's better for the patient's health, and it's better for society because effective therapy stops transmission of the disease, he said.

All HIV-positive individuals could be logged into a computer-based tracking system so local public health departments could identify those who don't have an undetectable viral load and visit them to find out why, Dr. Conant proposed.

He said he had no relevant financial disclosures.

SEOUL, SOUTH KOREA – It is time for a new strategy aimed at preventing HIV infection in the United States, an AIDS expert said at the World Congress of Dermatology.

This strategy ought to be built around universal testing, treatment starting at the moment of diagnosis, and public health monitoring of compliance, said Dr. Marcus Conant, a dermatologist at the University of California, San Francisco, who in 1981 was among the first physicians to identify AIDS and was a cofounder of the San Francisco AIDS Foundation.

The current prevention strategy has been in place since the 1980s. It is based on education about the use of condoms and other safe sex practices, along with voluntary testing for HIV – and it is simply not working.

Roughly 58,000 new cases of HIV have occurred annually in the United States over the past 15 years, with no drop-off trend. It is a prevention strategy that was developed when the epidemic was centered in the gay community. Now the epidemic is moving toward black and Hispanic individuals, who are poorly educated about HIV risk and don’t ask to be tested for HIV because they do not realize they are at risk.

"What was true 30 years ago is no longer true today, and yet we're caught in this time warp where we're not changing how we approach the disease. My message really is what we were doing 30 years ago was applicable then, but it's not applicable today," Dr. Conant said.

Today, one-third of HIV-positive individuals do not know they are infected. Another one-third are aware they are HIV positive but are not on highly active antiretroviral therapy (HAART), most often because they lack health insurance coverage. But it is the remaining third of HIV-infected individuals – those on drug therapy – who are of greatest concern, because only 19% of them have an undetectable viral load. The other 81% on drugs are potentially transmitting partially or totally resistant virus to their sex partners.

"It begs the question of how many years will it take until the virus in America is totally resistant to all of the drugs we currently have. We saw this happen with penicillin and Staphylococcus aureus. We've been there. We know this is going to happen. And yet we're sitting here watching it happen and doing very little about it," Dr. Conant said.

"With 58,000 newly infected individuals per year, and with only 19% of those being treated having undetectable viral loads, we are sitting on a prescription for disaster. Resistance is going to become a huge problem in the next decade," he warned.

Recent studies have demonstrated that early initiation of HAART results in longer survival, fewer side effects, and better compliance. Plus, patients having an undetectable viral load are at lower risk of transmitting the disease to a sex partner. That is why Dr. Conant believes that stopping the HIV epidemic requires testing everyone, treating everyone who is infected, and monitoring all infected individuals in order to strongly encourage maintaining an undetectable viral load.

Everybody, regardless of age, who has blood drawn for any reason – a routine physical exam, pregnancy, induction into the military – should have that blood sample tested for HIV, he said. Pooled polymerase chain reaction testing of low-risk groups, such as women, could be done to make universal testing more economical.

In any case, the pharmaceutical industry could easily foot the bill for universal testing. By identifying the one-third of HIV-positive individuals who do not know they’re infected, the drug companies stand to make a fortune in increased sales of HAART, according to Dr. Conant.

Current U.S. guidelines call for initiating HAART in HIV-positive patients with a CD4 count below 350 cells/mm³. But it makes more sense to begin treatment as soon as someone is found to be HIV positive, even though this practice isn't supported by randomized controlled trial evidence. It's better for the patient's health, and it's better for society because effective therapy stops transmission of the disease, he said.

All HIV-positive individuals could be logged into a computer-based tracking system so local public health departments could identify those who don't have an undetectable viral load and visit them to find out why, Dr. Conant proposed.

He said he had no relevant financial disclosures.