HIV

An updated recommendation from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) calling for universal hepatitis B vaccination of all adults aged 59 and younger has boosted the call to improve clinicians’ awareness of the increasing infection and low vaccination rates – and raise the issue with patients.

“This new recommendation from [the] ACIP will be instrumental [in] raising adult hepatitis B vaccination rates in the U.S. to levels that will allow us to finally eliminate hepatitis B in this country,” said Rita K. Kuwahara, MD, a primary care internal medicine physician and health policy fellow at Georgetown University, in Washington, D.C., in addressing the issue at the U.S. Conference on HIV/AIDS (USCHA) this month.

“We have the tools to prevent hepatitis B, and since we have such safe and highly effective vaccines to protect against community [spread], we should not have a single new infection in our nation,” she asserted.

The unanimously approved updated ACIP recommendation was issued in November and still requires adoption by the CDC director. The ACIP specifically recommends that adults aged 19 to 59 and those 60 years and older with risk factors for infection “should” receive the hepatitis B vaccine, and it further stipulates that those 60 years and older without known risk factors for hepatitis B “may” receive the vaccine.

The recommendation was previously only for adults at risk for hepatitis B infection due to a variety of factors, including sexual exposure, percutaneous or mucosal exposure to blood, hepatitis C infection, chronic liver disease, end-stage renal disease, and HIV infection.

“The number of risk factors was long, and for a busy primary care provider to have to go through a lengthy risk-based protocol like that, it may not happen,” Dr. Kuwahara told this news organization.

“Now we have a really helpful new recommendation that is simply age based, and clinicians can just tell patients that if they were born before this certain period, a hepatitis B vaccination is recommended.”

The change comes amid a troubling trajectory of hepatitis B, with up to 2.4 million individuals currently having chronic hepatitis B in the U.S. and infection rates soaring by 100% to more than 400% in states with high opioid use, such as West Virginia, Kentucky, Tennessee, and Maine, Dr. Kuwahara said.

Notably, hepatitis B is the leading cause of liver disease, and one in four individuals with unmanaged chronic hepatitis B goes on to develop liver failure and/or cirrhosis or liver cancer, which has a 5-year survival rate of only 18%.

Despite the rising infection rates, only 25%-30% of adults in the U.S. are reported to be currently vaccinated for hepatitis B, even though safe and highly effective vaccines are available, notably including a new two-dose vaccine (Heplisav-B) that can be provided over just a month (vs. other hepatitis B vaccines requiring 3 doses over 6 months).
 

Clinician awareness of low vaccination rates lacking

Dr. Kuwahara noted that awareness among clinicians of the issues surrounding hepatitis B appears low, with one small survey that she and her colleagues conducted of 30 primary care physicians showing that not one of the respondents was aware of the low vaccination rate.

Dr. Kuwahara says a key reason for the low awareness to discuss the hepatitis B vaccination with adults is the common impression that the responsibility for the vaccination lies in the hands of pediatricians.

But that’s only half correct – universal vaccination for hepatitis B in all infants and children is indeed currently the policy in the U.S. – but that was not implemented in all states until the mid-to-late ‘90s, meaning the millions of adults over the age of about 25 to 30, born before that period, are likely not fully vaccinated against hepatitis B.

“When I was in medical school, there wasn’t a lot of discussion of how low the hepatitis B vaccination rate was because everyone knew there was universal childhood vaccination, and I think there was an assumption that it had been going on for a long time,” Dr. Kuwahara said. “So I think it’s clearly a misconception, and it’s really important to improve clinician awareness around the issue.”
 

Opioid use a key factor in rising infection rates

Importantly, a large proportion of opioid users are among the population of patients born before the mid-’90s – and those adults have a particularly high risk of transmission, with data indicating that 36% of new hepatitis B infections are the result of the opioid epidemic, Dr. Kuwahara noted.

“In the opioid epidemic, we have seen some of the greatest increases in acute hepatitis B presenting in adults aged 30 to 49 years old, as most adults in this age range would not have been vaccinated as children in the U.S.,” she said.

Approximately two-thirds of individuals with chronic hepatitis B are reportedly not even aware of their infection status due to ineffective prevention and vaccination programs, adding to the spread of infection, Dr. Kuwahara said.

Meanwhile, COVID-19 has only exacerbated the problem, with record-high instances of overdoses and overdose-related deaths during the pandemic, she explained.

However, the pandemic, and specifically the sweeping innovations that have been implemented in desperate efforts to bring COVID-19 vaccines to the public, could in fact represent a critical opportunity for hepatitis B prevention, Dr. Kuwahara said.

“Significant resources and federal funding have already been invested to develop a robust infrastructure for multi-dose COVID-19 vaccine administration during the pandemic, which has resulted in millions of people across the U.S. receiving the COVID-19 vaccine in easily accessible settings within their communities,” she said.

“It is essential that we expand the infrastructure development ... so that we may use this infrastructure to administer other vaccines such as the hepatitis B vaccine to adults throughout the nation and prevent additional outbreaks.”
 

Implementation of vaccine recommendations key

Dr. Kuwahara outlined key measures that will be important in implementing the hepatitis B vaccine recommendations:

• Awareness of the hepatitis B vaccination recommendations at the primary care level: “The first step in implementing universal [guidelines] will be to ensure that health care providers, particularly in primary care, are aware of the new ACIP guidelines so that they can speak with their patients about this and appropriately order hepatitis B testing and vaccination,” she said.
• Availability of vaccines: In addition to making sure primary care clinics are well stocked with hepatitis B vaccines, the vaccines should also be available in pharmacies and other convenient nonclinical settings through community outreach, similar to COVID-19 vaccines.
• Follow-up: Systems should be established to remind patients to receive follow-up doses.
• Public funding for vaccines: Policy changes will need to occur to allocate appropriate Section 317 funding to provide hepatitis B vaccines to adults without health insurance coverage, Dr. Kuwahara said, underscoring concerns about health equity in vaccination.
• Track vaccinations: Communication should be established between places administering vaccines and primary care providers to make sure that vaccination status can be documented in a reliable setting.

Dr. Kuwahara also noted that a federal immunization information system will be essential to track vaccines across a lifespan, providing one integrated vaccine record that can be accessed even when patients travel or move to different states.

Commenting on the issue, Frank Hood, manager of hepatitis advocacy for The AIDS Institute in Washington, D.C., added that, in addition to simplifying the process, the new age-based recommendation removes the issue of perceived judgement from the advice.

“The previous recommendations were more risk based, and patients may tend to say ‘oh, I don’t have any of those behaviors,’ and there can be some stigma,” he said. “But having something that says everyone in these age groups should be or may be vaccinated just makes it much easier and covers a greater number of individuals.”

Mr. Hood further underscored the need for continued diligence in improving measures to prevent and eradicate HBV as well as other infectious diseases.

“It is imperative that the systems being built now to respond to future infectious disease outbreaks are done so in a way to equitably support the efforts and end goal of eliminating current infectious disease epidemics like viral hepatitis and HIV,” he emphasized.“Elimination can’t be achieved if we leave people behind.”

Dr. Kuwahara and Mr. Hood had no disclosures to report.

A version of this article first appeared on Medscape.com.

An updated recommendation from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) calling for universal hepatitis B vaccination of all adults aged 59 and younger has boosted the call to improve clinicians’ awareness of the increasing infection and low vaccination rates – and raise the issue with patients.

“This new recommendation from [the] ACIP will be instrumental [in] raising adult hepatitis B vaccination rates in the U.S. to levels that will allow us to finally eliminate hepatitis B in this country,” said Rita K. Kuwahara, MD, a primary care internal medicine physician and health policy fellow at Georgetown University, in Washington, D.C., in addressing the issue at the U.S. Conference on HIV/AIDS (USCHA) this month.

“We have the tools to prevent hepatitis B, and since we have such safe and highly effective vaccines to protect against community [spread], we should not have a single new infection in our nation,” she asserted.

The unanimously approved updated ACIP recommendation was issued in November and still requires adoption by the CDC director. The ACIP specifically recommends that adults aged 19 to 59 and those 60 years and older with risk factors for infection “should” receive the hepatitis B vaccine, and it further stipulates that those 60 years and older without known risk factors for hepatitis B “may” receive the vaccine.

The recommendation was previously only for adults at risk for hepatitis B infection due to a variety of factors, including sexual exposure, percutaneous or mucosal exposure to blood, hepatitis C infection, chronic liver disease, end-stage renal disease, and HIV infection.

“The number of risk factors was long, and for a busy primary care provider to have to go through a lengthy risk-based protocol like that, it may not happen,” Dr. Kuwahara told this news organization.

“Now we have a really helpful new recommendation that is simply age based, and clinicians can just tell patients that if they were born before this certain period, a hepatitis B vaccination is recommended.”

The change comes amid a troubling trajectory of hepatitis B, with up to 2.4 million individuals currently having chronic hepatitis B in the U.S. and infection rates soaring by 100% to more than 400% in states with high opioid use, such as West Virginia, Kentucky, Tennessee, and Maine, Dr. Kuwahara said.

Notably, hepatitis B is the leading cause of liver disease, and one in four individuals with unmanaged chronic hepatitis B goes on to develop liver failure and/or cirrhosis or liver cancer, which has a 5-year survival rate of only 18%.

Despite the rising infection rates, only 25%-30% of adults in the U.S. are reported to be currently vaccinated for hepatitis B, even though safe and highly effective vaccines are available, notably including a new two-dose vaccine (Heplisav-B) that can be provided over just a month (vs. other hepatitis B vaccines requiring 3 doses over 6 months).
 

Clinician awareness of low vaccination rates lacking

Dr. Kuwahara noted that awareness among clinicians of the issues surrounding hepatitis B appears low, with one small survey that she and her colleagues conducted of 30 primary care physicians showing that not one of the respondents was aware of the low vaccination rate.

Dr. Kuwahara says a key reason for the low awareness to discuss the hepatitis B vaccination with adults is the common impression that the responsibility for the vaccination lies in the hands of pediatricians.

But that’s only half correct – universal vaccination for hepatitis B in all infants and children is indeed currently the policy in the U.S. – but that was not implemented in all states until the mid-to-late ‘90s, meaning the millions of adults over the age of about 25 to 30, born before that period, are likely not fully vaccinated against hepatitis B.

“When I was in medical school, there wasn’t a lot of discussion of how low the hepatitis B vaccination rate was because everyone knew there was universal childhood vaccination, and I think there was an assumption that it had been going on for a long time,” Dr. Kuwahara said. “So I think it’s clearly a misconception, and it’s really important to improve clinician awareness around the issue.”
 

Opioid use a key factor in rising infection rates

Importantly, a large proportion of opioid users are among the population of patients born before the mid-’90s – and those adults have a particularly high risk of transmission, with data indicating that 36% of new hepatitis B infections are the result of the opioid epidemic, Dr. Kuwahara noted.

“In the opioid epidemic, we have seen some of the greatest increases in acute hepatitis B presenting in adults aged 30 to 49 years old, as most adults in this age range would not have been vaccinated as children in the U.S.,” she said.

Approximately two-thirds of individuals with chronic hepatitis B are reportedly not even aware of their infection status due to ineffective prevention and vaccination programs, adding to the spread of infection, Dr. Kuwahara said.

Meanwhile, COVID-19 has only exacerbated the problem, with record-high instances of overdoses and overdose-related deaths during the pandemic, she explained.

However, the pandemic, and specifically the sweeping innovations that have been implemented in desperate efforts to bring COVID-19 vaccines to the public, could in fact represent a critical opportunity for hepatitis B prevention, Dr. Kuwahara said.

“Significant resources and federal funding have already been invested to develop a robust infrastructure for multi-dose COVID-19 vaccine administration during the pandemic, which has resulted in millions of people across the U.S. receiving the COVID-19 vaccine in easily accessible settings within their communities,” she said.

“It is essential that we expand the infrastructure development ... so that we may use this infrastructure to administer other vaccines such as the hepatitis B vaccine to adults throughout the nation and prevent additional outbreaks.”
 

Implementation of vaccine recommendations key

Dr. Kuwahara outlined key measures that will be important in implementing the hepatitis B vaccine recommendations:

• Awareness of the hepatitis B vaccination recommendations at the primary care level: “The first step in implementing universal [guidelines] will be to ensure that health care providers, particularly in primary care, are aware of the new ACIP guidelines so that they can speak with their patients about this and appropriately order hepatitis B testing and vaccination,” she said.
• Availability of vaccines: In addition to making sure primary care clinics are well stocked with hepatitis B vaccines, the vaccines should also be available in pharmacies and other convenient nonclinical settings through community outreach, similar to COVID-19 vaccines.
• Follow-up: Systems should be established to remind patients to receive follow-up doses.
• Public funding for vaccines: Policy changes will need to occur to allocate appropriate Section 317 funding to provide hepatitis B vaccines to adults without health insurance coverage, Dr. Kuwahara said, underscoring concerns about health equity in vaccination.
• Track vaccinations: Communication should be established between places administering vaccines and primary care providers to make sure that vaccination status can be documented in a reliable setting.

Dr. Kuwahara also noted that a federal immunization information system will be essential to track vaccines across a lifespan, providing one integrated vaccine record that can be accessed even when patients travel or move to different states.

Commenting on the issue, Frank Hood, manager of hepatitis advocacy for The AIDS Institute in Washington, D.C., added that, in addition to simplifying the process, the new age-based recommendation removes the issue of perceived judgement from the advice.

“The previous recommendations were more risk based, and patients may tend to say ‘oh, I don’t have any of those behaviors,’ and there can be some stigma,” he said. “But having something that says everyone in these age groups should be or may be vaccinated just makes it much easier and covers a greater number of individuals.”

Mr. Hood further underscored the need for continued diligence in improving measures to prevent and eradicate HBV as well as other infectious diseases.

“It is imperative that the systems being built now to respond to future infectious disease outbreaks are done so in a way to equitably support the efforts and end goal of eliminating current infectious disease epidemics like viral hepatitis and HIV,” he emphasized.“Elimination can’t be achieved if we leave people behind.”

Dr. Kuwahara and Mr. Hood had no disclosures to report.

A version of this article first appeared on Medscape.com.

An updated recommendation from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) calling for universal hepatitis B vaccination of all adults aged 59 and younger has boosted the call to improve clinicians’ awareness of the increasing infection and low vaccination rates – and raise the issue with patients.

“This new recommendation from [the] ACIP will be instrumental [in] raising adult hepatitis B vaccination rates in the U.S. to levels that will allow us to finally eliminate hepatitis B in this country,” said Rita K. Kuwahara, MD, a primary care internal medicine physician and health policy fellow at Georgetown University, in Washington, D.C., in addressing the issue at the U.S. Conference on HIV/AIDS (USCHA) this month.

“We have the tools to prevent hepatitis B, and since we have such safe and highly effective vaccines to protect against community [spread], we should not have a single new infection in our nation,” she asserted.

The unanimously approved updated ACIP recommendation was issued in November and still requires adoption by the CDC director. The ACIP specifically recommends that adults aged 19 to 59 and those 60 years and older with risk factors for infection “should” receive the hepatitis B vaccine, and it further stipulates that those 60 years and older without known risk factors for hepatitis B “may” receive the vaccine.

The recommendation was previously only for adults at risk for hepatitis B infection due to a variety of factors, including sexual exposure, percutaneous or mucosal exposure to blood, hepatitis C infection, chronic liver disease, end-stage renal disease, and HIV infection.

“The number of risk factors was long, and for a busy primary care provider to have to go through a lengthy risk-based protocol like that, it may not happen,” Dr. Kuwahara told this news organization.

“Now we have a really helpful new recommendation that is simply age based, and clinicians can just tell patients that if they were born before this certain period, a hepatitis B vaccination is recommended.”

The change comes amid a troubling trajectory of hepatitis B, with up to 2.4 million individuals currently having chronic hepatitis B in the U.S. and infection rates soaring by 100% to more than 400% in states with high opioid use, such as West Virginia, Kentucky, Tennessee, and Maine, Dr. Kuwahara said.

Notably, hepatitis B is the leading cause of liver disease, and one in four individuals with unmanaged chronic hepatitis B goes on to develop liver failure and/or cirrhosis or liver cancer, which has a 5-year survival rate of only 18%.

Despite the rising infection rates, only 25%-30% of adults in the U.S. are reported to be currently vaccinated for hepatitis B, even though safe and highly effective vaccines are available, notably including a new two-dose vaccine (Heplisav-B) that can be provided over just a month (vs. other hepatitis B vaccines requiring 3 doses over 6 months).
 

Clinician awareness of low vaccination rates lacking

Dr. Kuwahara noted that awareness among clinicians of the issues surrounding hepatitis B appears low, with one small survey that she and her colleagues conducted of 30 primary care physicians showing that not one of the respondents was aware of the low vaccination rate.

Dr. Kuwahara says a key reason for the low awareness to discuss the hepatitis B vaccination with adults is the common impression that the responsibility for the vaccination lies in the hands of pediatricians.

But that’s only half correct – universal vaccination for hepatitis B in all infants and children is indeed currently the policy in the U.S. – but that was not implemented in all states until the mid-to-late ‘90s, meaning the millions of adults over the age of about 25 to 30, born before that period, are likely not fully vaccinated against hepatitis B.

“When I was in medical school, there wasn’t a lot of discussion of how low the hepatitis B vaccination rate was because everyone knew there was universal childhood vaccination, and I think there was an assumption that it had been going on for a long time,” Dr. Kuwahara said. “So I think it’s clearly a misconception, and it’s really important to improve clinician awareness around the issue.”
 

Opioid use a key factor in rising infection rates

Importantly, a large proportion of opioid users are among the population of patients born before the mid-’90s – and those adults have a particularly high risk of transmission, with data indicating that 36% of new hepatitis B infections are the result of the opioid epidemic, Dr. Kuwahara noted.

“In the opioid epidemic, we have seen some of the greatest increases in acute hepatitis B presenting in adults aged 30 to 49 years old, as most adults in this age range would not have been vaccinated as children in the U.S.,” she said.

Approximately two-thirds of individuals with chronic hepatitis B are reportedly not even aware of their infection status due to ineffective prevention and vaccination programs, adding to the spread of infection, Dr. Kuwahara said.

Meanwhile, COVID-19 has only exacerbated the problem, with record-high instances of overdoses and overdose-related deaths during the pandemic, she explained.

However, the pandemic, and specifically the sweeping innovations that have been implemented in desperate efforts to bring COVID-19 vaccines to the public, could in fact represent a critical opportunity for hepatitis B prevention, Dr. Kuwahara said.

“Significant resources and federal funding have already been invested to develop a robust infrastructure for multi-dose COVID-19 vaccine administration during the pandemic, which has resulted in millions of people across the U.S. receiving the COVID-19 vaccine in easily accessible settings within their communities,” she said.

“It is essential that we expand the infrastructure development ... so that we may use this infrastructure to administer other vaccines such as the hepatitis B vaccine to adults throughout the nation and prevent additional outbreaks.”
 

Implementation of vaccine recommendations key

Dr. Kuwahara outlined key measures that will be important in implementing the hepatitis B vaccine recommendations:

• Awareness of the hepatitis B vaccination recommendations at the primary care level: “The first step in implementing universal [guidelines] will be to ensure that health care providers, particularly in primary care, are aware of the new ACIP guidelines so that they can speak with their patients about this and appropriately order hepatitis B testing and vaccination,” she said.
• Availability of vaccines: In addition to making sure primary care clinics are well stocked with hepatitis B vaccines, the vaccines should also be available in pharmacies and other convenient nonclinical settings through community outreach, similar to COVID-19 vaccines.
• Follow-up: Systems should be established to remind patients to receive follow-up doses.
• Public funding for vaccines: Policy changes will need to occur to allocate appropriate Section 317 funding to provide hepatitis B vaccines to adults without health insurance coverage, Dr. Kuwahara said, underscoring concerns about health equity in vaccination.
• Track vaccinations: Communication should be established between places administering vaccines and primary care providers to make sure that vaccination status can be documented in a reliable setting.

Dr. Kuwahara also noted that a federal immunization information system will be essential to track vaccines across a lifespan, providing one integrated vaccine record that can be accessed even when patients travel or move to different states.

Commenting on the issue, Frank Hood, manager of hepatitis advocacy for The AIDS Institute in Washington, D.C., added that, in addition to simplifying the process, the new age-based recommendation removes the issue of perceived judgement from the advice.

“The previous recommendations were more risk based, and patients may tend to say ‘oh, I don’t have any of those behaviors,’ and there can be some stigma,” he said. “But having something that says everyone in these age groups should be or may be vaccinated just makes it much easier and covers a greater number of individuals.”

Mr. Hood further underscored the need for continued diligence in improving measures to prevent and eradicate HBV as well as other infectious diseases.

“It is imperative that the systems being built now to respond to future infectious disease outbreaks are done so in a way to equitably support the efforts and end goal of eliminating current infectious disease epidemics like viral hepatitis and HIV,” he emphasized.“Elimination can’t be achieved if we leave people behind.”

Dr. Kuwahara and Mr. Hood had no disclosures to report.

A version of this article first appeared on Medscape.com.

HIV testing centers across the United States showed reductions in testing of nearly 50% during the height of the COVID-19 pandemic in 2020, raising concerns of a subsequent increase in transmission by people unaware of their HIV-positive status.

“Testing strategies need to be ramped up to cover this decrease in testing while adapting to the continuing COVID-19 environment,” reported Deesha Patel, MPH, and colleagues with the Centers for Disease Control and Prevention’s division of HIV prevention, Atlanta, in research presented at the annual meeting of the United States Conference on HIV/AIDS.

According to their data from the National HIV Prevention Program Monitoring and Evaluation system, the number of CDC-funded HIV tests declined by more than 1 million in 2020 amid the COVID-19 restrictions, with 1,228,142 tests reported that year, compared with 2,301,669 tests in 2019, a reduction of 46.6%.

The number of persons who were newly diagnosed with HIV, based on the tests, declined by 29.7%, from 7,692 newly diagnosed in 2019 to 5,409 persons in 2020, the authors reported.

The reasons for the reduction in new HIV diagnoses in 2020 could be multifactorial, possibly reflecting not just the reduced rates of testing but also possibly lower rates of transmission because of the lockdowns and social distancing, Mr. Patel said in an interview.

“Both [of those] interpretations are plausible, and the reductions are likely due to a combination of reasons,” she said.

Of note, the percentage of tests that were positive did not show a decline and was in fact slightly higher in 2020 (0.4%), compared with 2019 (0.3%; rate ratio, 1.32). But the increase may reflect that those seeking testing during the pandemic were more likely to be symptomatic.

“It is plausible that the smaller pool of people getting tested represented those with a higher likelihood of receiving a positive HIV test, [for instance] having a recent exposure, exhibiting symptoms,” Mr. Patel explained. “Furthermore, it is possible that some health departments specifically focused outreach efforts to serve persons with increased potential for HIV acquisition, thus identifying a higher proportion of persons with HIV.”

The declines in testing are nevertheless of particular concern in light of recent pre-COVID data indicating that as many as 13% of people who were infected with HIV were unaware of their positive status, placing them at high risk of transmitting the virus.

And on a broader level, the declines could negatively affect the goal to eradicate HIV through the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the United States by 90% by 2030 through the scaling up of key HIV prevention and treatment strategies, Mr. Patel noted.

“The first pillar of EHE is to diagnose all people with HIV as early as possible, and to accomplish that, there needs to be sufficient HIV testing,” Mr. Patel explained. “With fewer HIV tests being conducted, there are missed opportunities to identify persons with newly diagnosed HIV, which affects the entire continuum of care, [including] linkage to medical care, receiving antiretroviral treatment, getting and keeping viral suppression, and reducing transmission.”
 

At the local level: Adaptations allowed for continued testing

In a separate report presented at the meeting detailing the experiences at a more local level, Joseph Olsen, MPH, and colleagues with CrescentCare, New Orleans, described a similar reduction of HIV testing in 2020 of 49% in their system, compared with the previous year, down from 7,952 rapid HIV tests in 2019 to 4,034 in 2020.

However, through efforts to continue to provide services during the pandemic, the program was able to link 182 patients to HIV care in 2020, which was up from 172 in 2019.

In addition to offering the rapid HIV testing in conjunction with COVID-19 testing at their urgent care centers, the center adapted to the pandemic’s challenges with strategies including a new at-home testing program; providing testing at a hotel shelter for the homeless; and testing as part of walk-in testing with a syringe access component.

Mr. Olsen credited the swift program adaptations with maintaining testing during the time of crisis.

“Without [those] measures, it would have been a near-zero number of tests provided,” he said in an interview. “It would have been easy to blame the pandemic and not try to find innovations to deliver services, but I credit our incredibly motivated team for wanting to make sure every possible resource was available.”

But now there are signs of possible fallout from the testing reductions that did occur, Mr. Olsen said.

“We are already seeing the increase with other sexually transmitted infections [STIs], and I expect that we will see this with HIV as well,” he said.

In response, clinicians should use diligence in providing HIV testing, Mr. Olsen asserted.

“The take-home message for clinicians is that anyone having sex should get tested for HIV. It’s as easy as that!” he said.

“If they are getting tested for any other STI, make sure an HIV panel is added and discussed. If someone is pregnant, make sure an HIV panel is added and discussed. If someone has never had an HIV test before in their life – and I would add if they haven’t had an HIV test since March of 2020 – make sure an HIV panel is added/discussed,” he said. “Doing this for everyone also reduces stigma around testing. It’s not because any one person or group or risk behavior is being targeted, it is just good public health practice.”

The authors disclosed no relevant financial relationships. Mr. Patel noted that the findings and conclusions of her poster are those of the authors and do not necessarily represent the official position of the CDC.

A version of this article first appeared on Medscape.com.

HIV testing centers across the United States showed reductions in testing of nearly 50% during the height of the COVID-19 pandemic in 2020, raising concerns of a subsequent increase in transmission by people unaware of their HIV-positive status.

“Testing strategies need to be ramped up to cover this decrease in testing while adapting to the continuing COVID-19 environment,” reported Deesha Patel, MPH, and colleagues with the Centers for Disease Control and Prevention’s division of HIV prevention, Atlanta, in research presented at the annual meeting of the United States Conference on HIV/AIDS.

According to their data from the National HIV Prevention Program Monitoring and Evaluation system, the number of CDC-funded HIV tests declined by more than 1 million in 2020 amid the COVID-19 restrictions, with 1,228,142 tests reported that year, compared with 2,301,669 tests in 2019, a reduction of 46.6%.

The number of persons who were newly diagnosed with HIV, based on the tests, declined by 29.7%, from 7,692 newly diagnosed in 2019 to 5,409 persons in 2020, the authors reported.

The reasons for the reduction in new HIV diagnoses in 2020 could be multifactorial, possibly reflecting not just the reduced rates of testing but also possibly lower rates of transmission because of the lockdowns and social distancing, Mr. Patel said in an interview.

“Both [of those] interpretations are plausible, and the reductions are likely due to a combination of reasons,” she said.

Of note, the percentage of tests that were positive did not show a decline and was in fact slightly higher in 2020 (0.4%), compared with 2019 (0.3%; rate ratio, 1.32). But the increase may reflect that those seeking testing during the pandemic were more likely to be symptomatic.

“It is plausible that the smaller pool of people getting tested represented those with a higher likelihood of receiving a positive HIV test, [for instance] having a recent exposure, exhibiting symptoms,” Mr. Patel explained. “Furthermore, it is possible that some health departments specifically focused outreach efforts to serve persons with increased potential for HIV acquisition, thus identifying a higher proportion of persons with HIV.”

The declines in testing are nevertheless of particular concern in light of recent pre-COVID data indicating that as many as 13% of people who were infected with HIV were unaware of their positive status, placing them at high risk of transmitting the virus.

And on a broader level, the declines could negatively affect the goal to eradicate HIV through the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the United States by 90% by 2030 through the scaling up of key HIV prevention and treatment strategies, Mr. Patel noted.

“The first pillar of EHE is to diagnose all people with HIV as early as possible, and to accomplish that, there needs to be sufficient HIV testing,” Mr. Patel explained. “With fewer HIV tests being conducted, there are missed opportunities to identify persons with newly diagnosed HIV, which affects the entire continuum of care, [including] linkage to medical care, receiving antiretroviral treatment, getting and keeping viral suppression, and reducing transmission.”
 

At the local level: Adaptations allowed for continued testing

In a separate report presented at the meeting detailing the experiences at a more local level, Joseph Olsen, MPH, and colleagues with CrescentCare, New Orleans, described a similar reduction of HIV testing in 2020 of 49% in their system, compared with the previous year, down from 7,952 rapid HIV tests in 2019 to 4,034 in 2020.

However, through efforts to continue to provide services during the pandemic, the program was able to link 182 patients to HIV care in 2020, which was up from 172 in 2019.

In addition to offering the rapid HIV testing in conjunction with COVID-19 testing at their urgent care centers, the center adapted to the pandemic’s challenges with strategies including a new at-home testing program; providing testing at a hotel shelter for the homeless; and testing as part of walk-in testing with a syringe access component.

Mr. Olsen credited the swift program adaptations with maintaining testing during the time of crisis.

“Without [those] measures, it would have been a near-zero number of tests provided,” he said in an interview. “It would have been easy to blame the pandemic and not try to find innovations to deliver services, but I credit our incredibly motivated team for wanting to make sure every possible resource was available.”

But now there are signs of possible fallout from the testing reductions that did occur, Mr. Olsen said.

“We are already seeing the increase with other sexually transmitted infections [STIs], and I expect that we will see this with HIV as well,” he said.

In response, clinicians should use diligence in providing HIV testing, Mr. Olsen asserted.

“The take-home message for clinicians is that anyone having sex should get tested for HIV. It’s as easy as that!” he said.

“If they are getting tested for any other STI, make sure an HIV panel is added and discussed. If someone is pregnant, make sure an HIV panel is added and discussed. If someone has never had an HIV test before in their life – and I would add if they haven’t had an HIV test since March of 2020 – make sure an HIV panel is added/discussed,” he said. “Doing this for everyone also reduces stigma around testing. It’s not because any one person or group or risk behavior is being targeted, it is just good public health practice.”

The authors disclosed no relevant financial relationships. Mr. Patel noted that the findings and conclusions of her poster are those of the authors and do not necessarily represent the official position of the CDC.

A version of this article first appeared on Medscape.com.

HIV testing centers across the United States showed reductions in testing of nearly 50% during the height of the COVID-19 pandemic in 2020, raising concerns of a subsequent increase in transmission by people unaware of their HIV-positive status.

“Testing strategies need to be ramped up to cover this decrease in testing while adapting to the continuing COVID-19 environment,” reported Deesha Patel, MPH, and colleagues with the Centers for Disease Control and Prevention’s division of HIV prevention, Atlanta, in research presented at the annual meeting of the United States Conference on HIV/AIDS.

According to their data from the National HIV Prevention Program Monitoring and Evaluation system, the number of CDC-funded HIV tests declined by more than 1 million in 2020 amid the COVID-19 restrictions, with 1,228,142 tests reported that year, compared with 2,301,669 tests in 2019, a reduction of 46.6%.

The number of persons who were newly diagnosed with HIV, based on the tests, declined by 29.7%, from 7,692 newly diagnosed in 2019 to 5,409 persons in 2020, the authors reported.

The reasons for the reduction in new HIV diagnoses in 2020 could be multifactorial, possibly reflecting not just the reduced rates of testing but also possibly lower rates of transmission because of the lockdowns and social distancing, Mr. Patel said in an interview.

“Both [of those] interpretations are plausible, and the reductions are likely due to a combination of reasons,” she said.

Of note, the percentage of tests that were positive did not show a decline and was in fact slightly higher in 2020 (0.4%), compared with 2019 (0.3%; rate ratio, 1.32). But the increase may reflect that those seeking testing during the pandemic were more likely to be symptomatic.

“It is plausible that the smaller pool of people getting tested represented those with a higher likelihood of receiving a positive HIV test, [for instance] having a recent exposure, exhibiting symptoms,” Mr. Patel explained. “Furthermore, it is possible that some health departments specifically focused outreach efforts to serve persons with increased potential for HIV acquisition, thus identifying a higher proportion of persons with HIV.”

The declines in testing are nevertheless of particular concern in light of recent pre-COVID data indicating that as many as 13% of people who were infected with HIV were unaware of their positive status, placing them at high risk of transmitting the virus.

And on a broader level, the declines could negatively affect the goal to eradicate HIV through the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the United States by 90% by 2030 through the scaling up of key HIV prevention and treatment strategies, Mr. Patel noted.

“The first pillar of EHE is to diagnose all people with HIV as early as possible, and to accomplish that, there needs to be sufficient HIV testing,” Mr. Patel explained. “With fewer HIV tests being conducted, there are missed opportunities to identify persons with newly diagnosed HIV, which affects the entire continuum of care, [including] linkage to medical care, receiving antiretroviral treatment, getting and keeping viral suppression, and reducing transmission.”
 

At the local level: Adaptations allowed for continued testing

In a separate report presented at the meeting detailing the experiences at a more local level, Joseph Olsen, MPH, and colleagues with CrescentCare, New Orleans, described a similar reduction of HIV testing in 2020 of 49% in their system, compared with the previous year, down from 7,952 rapid HIV tests in 2019 to 4,034 in 2020.

However, through efforts to continue to provide services during the pandemic, the program was able to link 182 patients to HIV care in 2020, which was up from 172 in 2019.

In addition to offering the rapid HIV testing in conjunction with COVID-19 testing at their urgent care centers, the center adapted to the pandemic’s challenges with strategies including a new at-home testing program; providing testing at a hotel shelter for the homeless; and testing as part of walk-in testing with a syringe access component.

Mr. Olsen credited the swift program adaptations with maintaining testing during the time of crisis.

“Without [those] measures, it would have been a near-zero number of tests provided,” he said in an interview. “It would have been easy to blame the pandemic and not try to find innovations to deliver services, but I credit our incredibly motivated team for wanting to make sure every possible resource was available.”

But now there are signs of possible fallout from the testing reductions that did occur, Mr. Olsen said.

“We are already seeing the increase with other sexually transmitted infections [STIs], and I expect that we will see this with HIV as well,” he said.

In response, clinicians should use diligence in providing HIV testing, Mr. Olsen asserted.

“The take-home message for clinicians is that anyone having sex should get tested for HIV. It’s as easy as that!” he said.

“If they are getting tested for any other STI, make sure an HIV panel is added and discussed. If someone is pregnant, make sure an HIV panel is added and discussed. If someone has never had an HIV test before in their life – and I would add if they haven’t had an HIV test since March of 2020 – make sure an HIV panel is added/discussed,” he said. “Doing this for everyone also reduces stigma around testing. It’s not because any one person or group or risk behavior is being targeted, it is just good public health practice.”

The authors disclosed no relevant financial relationships. Mr. Patel noted that the findings and conclusions of her poster are those of the authors and do not necessarily represent the official position of the CDC.

A version of this article first appeared on Medscape.com.

The majority of people with HIV and type 2 diabetes do not receive the recommended routine screenings necessary to prevent chronic complications associated with that comorbidity, research shows.

“Despite known risk in this patient population, most patients were not up to date with routine preventative screenings,” report Maya Hardman, PharmD, and colleagues with Southwest CARE Center, in Santa Fe, New Mexico, in research presented at the United States Conference on HIV/AIDS (USCHA) 2021 Annual Meeting.

“Routine preventative screenings can help identify chronic complications of diabetes early, if performed at the recommended intervals,” they write.

People with HIV are known to be at an increased risk of diabetes and the long-term complications of the disease, making the need for routine screening to prevent such complications all the more pressing due to their higher-risk health status.

Among the key routine diabetes care quality measures recommended by the Healthcare Effectiveness Data and Information Set (HEDIS) for people with HIV are testing for A1c once every 3 months, foot and eye exams every 12 months, urine albumin creatinine ratio (UACR) screenings every 12 months, and two controlled blood pressure readings every 12 months.

To investigate the rates of adherence to the HEDIS screening recommendations and identify predictors of poor compliance among people with HIV, Dr. Hardman and her colleagues evaluated data on 121 adult patients at the Southwest CARE Center who had been diagnosed with diabetes and HIV and were treated between 2019 and 2020.

The patients had a mean age of 57.5, and 9% were female. Their mean duration of being HIV positive was 19.8 years, and they had an intermediate Atherosclerotic Cardiovascular Disease (ASCVD) risk score of 17.08%.

Despite their known diagnoses of having diabetes, as many as 93.4% were found not to be up to date on their routine preventive screenings.

Of the 121 patients, only 30 had received the recommended A1c screenings, 37 had the recommended UACR screenings, and just 18 had received the recommended foot exam screenings.

Only blood pressure screenings, reported in 90 of the 121 patients, were up to date in the majority of patients in the group.

In looking at factors associated with compliance with A1c screening, only age (OR, 0.95; P = .04) was a significant predictor.

The authors pointed out that routine screenings for diabetes complications are relatively easy to implement.

“Screening for these chronic complications is minimally invasive and can be provided by individuals trained in diabetes management during routine clinic appointments.”

The team’s ongoing research is evaluating the potential benefits of clinical pharmacy services in assisting with the screenings for patients with HIV.

Research underscoring the increased risk and poorer treatment outcomes of diabetes in people with HIV include a study comparing 337 people with HIV in 2005 with a cohort of 338 participants in 2015.

The study showed the prevalence of type 2 diabetes had increased to 15.1% in 2015 from 6.8% 10 years earlier, for a relative risk of 2.4 compared with the general population.

“The alarmingly high prevalence of type 2 diabetes in HIV requires improved screening, targeted to older patients and those with a longer duration of exposure to antiretrovirals,” the authors wrote.

“Effective diabetes prevention and management strategies are needed urgently to reduce this risk; such interventions should target both conventional risk factors, such as abdominal obesity and HIV-specific risk factors such as weight gain following initiation of antiretrovirals.”

Of note, the 2015 cohort was significantly older and had higher BMI and higher hypertension than the 2005 cohort.

First author Alastair Duncan, PhD, principal dietitian at Guy’s & St. Thomas’ Hospital and lecturer, King’s College London, noted that since that 2015 study was published, concerns particularly with weight gain in the HIV population have only increased.

“Weight gain appears to be more of an issue [now],” he told this news organization in an interview.

“As in the general population, people living with HIV experienced significant weight gain during COVID-related lockdowns. Added to the high number of people living with HIV being treated with integrase inhibitors, weight gain remains a challenge.”

Meanwhile, “there are not enough studies comparing people living with HIV with the general population,” Dr. Duncan added. “We need to conduct studies where participants are matched.”

Sudipa Sarkar, MD, who co-authored a report on the issue of diabetes and HIV this year but was not involved in the study presented at USCHA, noted that the setting of care could play an important role in the quality of screening for diabetes that people with HIV receive.

“It may depend on factors such as whether a patient is being followed regularly by an HIV care provider and the larger health care system that the patient is in,” Dr. Sarkar, an assistant professor of medicine at Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, told this news organization.

“For example, one might find differences between a patient being seen in a managed care group versus not.”

The issue of how the strikingly high rates of inadequate screening in the current study compare with routine screening in the general diabetes population “is a good question and warrants more research,” she said.

The authors and Dr. Sarkar have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The majority of people with HIV and type 2 diabetes do not receive the recommended routine screenings necessary to prevent chronic complications associated with that comorbidity, research shows.

“Despite known risk in this patient population, most patients were not up to date with routine preventative screenings,” report Maya Hardman, PharmD, and colleagues with Southwest CARE Center, in Santa Fe, New Mexico, in research presented at the United States Conference on HIV/AIDS (USCHA) 2021 Annual Meeting.

“Routine preventative screenings can help identify chronic complications of diabetes early, if performed at the recommended intervals,” they write.

People with HIV are known to be at an increased risk of diabetes and the long-term complications of the disease, making the need for routine screening to prevent such complications all the more pressing due to their higher-risk health status.

Among the key routine diabetes care quality measures recommended by the Healthcare Effectiveness Data and Information Set (HEDIS) for people with HIV are testing for A1c once every 3 months, foot and eye exams every 12 months, urine albumin creatinine ratio (UACR) screenings every 12 months, and two controlled blood pressure readings every 12 months.

To investigate the rates of adherence to the HEDIS screening recommendations and identify predictors of poor compliance among people with HIV, Dr. Hardman and her colleagues evaluated data on 121 adult patients at the Southwest CARE Center who had been diagnosed with diabetes and HIV and were treated between 2019 and 2020.

The patients had a mean age of 57.5, and 9% were female. Their mean duration of being HIV positive was 19.8 years, and they had an intermediate Atherosclerotic Cardiovascular Disease (ASCVD) risk score of 17.08%.

Despite their known diagnoses of having diabetes, as many as 93.4% were found not to be up to date on their routine preventive screenings.

Of the 121 patients, only 30 had received the recommended A1c screenings, 37 had the recommended UACR screenings, and just 18 had received the recommended foot exam screenings.

Only blood pressure screenings, reported in 90 of the 121 patients, were up to date in the majority of patients in the group.

In looking at factors associated with compliance with A1c screening, only age (OR, 0.95; P = .04) was a significant predictor.

The authors pointed out that routine screenings for diabetes complications are relatively easy to implement.

“Screening for these chronic complications is minimally invasive and can be provided by individuals trained in diabetes management during routine clinic appointments.”

The team’s ongoing research is evaluating the potential benefits of clinical pharmacy services in assisting with the screenings for patients with HIV.

Research underscoring the increased risk and poorer treatment outcomes of diabetes in people with HIV include a study comparing 337 people with HIV in 2005 with a cohort of 338 participants in 2015.

The study showed the prevalence of type 2 diabetes had increased to 15.1% in 2015 from 6.8% 10 years earlier, for a relative risk of 2.4 compared with the general population.

“The alarmingly high prevalence of type 2 diabetes in HIV requires improved screening, targeted to older patients and those with a longer duration of exposure to antiretrovirals,” the authors wrote.

“Effective diabetes prevention and management strategies are needed urgently to reduce this risk; such interventions should target both conventional risk factors, such as abdominal obesity and HIV-specific risk factors such as weight gain following initiation of antiretrovirals.”

Of note, the 2015 cohort was significantly older and had higher BMI and higher hypertension than the 2005 cohort.

First author Alastair Duncan, PhD, principal dietitian at Guy’s & St. Thomas’ Hospital and lecturer, King’s College London, noted that since that 2015 study was published, concerns particularly with weight gain in the HIV population have only increased.

“Weight gain appears to be more of an issue [now],” he told this news organization in an interview.

“As in the general population, people living with HIV experienced significant weight gain during COVID-related lockdowns. Added to the high number of people living with HIV being treated with integrase inhibitors, weight gain remains a challenge.”

Meanwhile, “there are not enough studies comparing people living with HIV with the general population,” Dr. Duncan added. “We need to conduct studies where participants are matched.”

Sudipa Sarkar, MD, who co-authored a report on the issue of diabetes and HIV this year but was not involved in the study presented at USCHA, noted that the setting of care could play an important role in the quality of screening for diabetes that people with HIV receive.

“It may depend on factors such as whether a patient is being followed regularly by an HIV care provider and the larger health care system that the patient is in,” Dr. Sarkar, an assistant professor of medicine at Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, told this news organization.

“For example, one might find differences between a patient being seen in a managed care group versus not.”

The issue of how the strikingly high rates of inadequate screening in the current study compare with routine screening in the general diabetes population “is a good question and warrants more research,” she said.

The authors and Dr. Sarkar have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The majority of people with HIV and type 2 diabetes do not receive the recommended routine screenings necessary to prevent chronic complications associated with that comorbidity, research shows.

“Despite known risk in this patient population, most patients were not up to date with routine preventative screenings,” report Maya Hardman, PharmD, and colleagues with Southwest CARE Center, in Santa Fe, New Mexico, in research presented at the United States Conference on HIV/AIDS (USCHA) 2021 Annual Meeting.

“Routine preventative screenings can help identify chronic complications of diabetes early, if performed at the recommended intervals,” they write.

People with HIV are known to be at an increased risk of diabetes and the long-term complications of the disease, making the need for routine screening to prevent such complications all the more pressing due to their higher-risk health status.

Among the key routine diabetes care quality measures recommended by the Healthcare Effectiveness Data and Information Set (HEDIS) for people with HIV are testing for A1c once every 3 months, foot and eye exams every 12 months, urine albumin creatinine ratio (UACR) screenings every 12 months, and two controlled blood pressure readings every 12 months.

To investigate the rates of adherence to the HEDIS screening recommendations and identify predictors of poor compliance among people with HIV, Dr. Hardman and her colleagues evaluated data on 121 adult patients at the Southwest CARE Center who had been diagnosed with diabetes and HIV and were treated between 2019 and 2020.

The patients had a mean age of 57.5, and 9% were female. Their mean duration of being HIV positive was 19.8 years, and they had an intermediate Atherosclerotic Cardiovascular Disease (ASCVD) risk score of 17.08%.

Despite their known diagnoses of having diabetes, as many as 93.4% were found not to be up to date on their routine preventive screenings.

Of the 121 patients, only 30 had received the recommended A1c screenings, 37 had the recommended UACR screenings, and just 18 had received the recommended foot exam screenings.

Only blood pressure screenings, reported in 90 of the 121 patients, were up to date in the majority of patients in the group.

In looking at factors associated with compliance with A1c screening, only age (OR, 0.95; P = .04) was a significant predictor.

The authors pointed out that routine screenings for diabetes complications are relatively easy to implement.

“Screening for these chronic complications is minimally invasive and can be provided by individuals trained in diabetes management during routine clinic appointments.”

The team’s ongoing research is evaluating the potential benefits of clinical pharmacy services in assisting with the screenings for patients with HIV.

Research underscoring the increased risk and poorer treatment outcomes of diabetes in people with HIV include a study comparing 337 people with HIV in 2005 with a cohort of 338 participants in 2015.

The study showed the prevalence of type 2 diabetes had increased to 15.1% in 2015 from 6.8% 10 years earlier, for a relative risk of 2.4 compared with the general population.

“The alarmingly high prevalence of type 2 diabetes in HIV requires improved screening, targeted to older patients and those with a longer duration of exposure to antiretrovirals,” the authors wrote.

“Effective diabetes prevention and management strategies are needed urgently to reduce this risk; such interventions should target both conventional risk factors, such as abdominal obesity and HIV-specific risk factors such as weight gain following initiation of antiretrovirals.”

Of note, the 2015 cohort was significantly older and had higher BMI and higher hypertension than the 2005 cohort.

First author Alastair Duncan, PhD, principal dietitian at Guy’s & St. Thomas’ Hospital and lecturer, King’s College London, noted that since that 2015 study was published, concerns particularly with weight gain in the HIV population have only increased.

“Weight gain appears to be more of an issue [now],” he told this news organization in an interview.

“As in the general population, people living with HIV experienced significant weight gain during COVID-related lockdowns. Added to the high number of people living with HIV being treated with integrase inhibitors, weight gain remains a challenge.”

Meanwhile, “there are not enough studies comparing people living with HIV with the general population,” Dr. Duncan added. “We need to conduct studies where participants are matched.”

Sudipa Sarkar, MD, who co-authored a report on the issue of diabetes and HIV this year but was not involved in the study presented at USCHA, noted that the setting of care could play an important role in the quality of screening for diabetes that people with HIV receive.

“It may depend on factors such as whether a patient is being followed regularly by an HIV care provider and the larger health care system that the patient is in,” Dr. Sarkar, an assistant professor of medicine at Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, told this news organization.

“For example, one might find differences between a patient being seen in a managed care group versus not.”

The issue of how the strikingly high rates of inadequate screening in the current study compare with routine screening in the general diabetes population “is a good question and warrants more research,” she said.

The authors and Dr. Sarkar have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Starting Dec. 8, the Centers for Disease Control and Prevention recommends all clinicians talk to their sexually active adolescent and adult patients about HIV pre-exposure prophylaxis (PrEP) at least once and prescribe the prevention pills to anyone who asks for them, whether or not you understand their need for it.

“PrEP is a part of good primary care,” Demetre Daskalakis, MD, CDC’s director of the division of HIV/AIDS prevention, said in an interview. “Listening to people and what they need, as opposed to assessing what you think they need, is a seismic shift in how PrEP should be offered.”

The expanded recommendation comes as part of the 2021 update to the U.S. Public Health Service’s PrEP prescribing guidelines. It’s the third iteration since the Food and Drug Administration approved the first HIV prevention pill in 2012, and the first to include guidance on how to prescribe and monitor an injectable version of PrEP, which the FDA may approve as early as December 2021.

There are currently two pills, Truvada (emtricitabine/tenofovir disoproxil fumarate, Gilead Sciences and generic) and Descovy (emtricitabine/tenofovir alafenamide, Gilead Sciences). The pills have been found to be up to 99% effective in preventing HIV acquisition. The new injectable cabotegravir appears to be even more effective.

The broadened guidance is part of an effort from the country’s top health officials to expand PrEP prescribing from infectious disease specialists and sexual health clinics to health care professionals, including gynecologists, internal medicine physicians, and family practice clinicians. It appears to be necessary. In 2020, just 25% of the 1.2 million Americans who could benefit from PrEP were taking it, according to CDC data.

But those rates belie stark disparities in PrEP use by race and gender. The vast majority of those using PrEP are White Americans and men. About 66% of White Americans who could benefit from PrEP used it in 2020, and more than a quarter of the men who could benefit used it. By contrast, just 16% of Latinx people who could benefit had a prescription. And fewer than 1 in 10 Black Americans, who make up nearly half of those with indications for PrEP, had a prescription. The same was true for the women who could benefit.

Researchers and data from early PrEP demonstration projects have documented that clinicians are less likely to refer or prescribe the HIV prevention pills to Black people, especially the Black cisgender and transgender women and same-gender-loving men who bear the disproportionate burden of new cases in the United States, as well as fail to prescribe the medication to people who inject drugs.
 

Normalizing PrEP in primary care

When Courtney Sherman, DNP, APRN, first heard about PrEP in the early 2010s, she joked that her reaction was: “You’re ridiculous. You’re making that up. That’s not real.”

Ms. Sherman is now launching a tele-PrEP program from CAN Community Health, a nonprofit network of community health centers in southern Florida. The tele-PrEP program is meant to serve people in Florida and beyond, to increase access to the pill in areas with few health care professionals, or clinicians unwilling to prescribe it.

“When I go other places, I can’t do what I do for a living without getting some sort of bizarre comment or look,” she said. But the looks don’t just come from family, friends, or her children’s teachers. They come from colleagues, too. “What I’ve learned is that anybody – anybody – can be impacted [by HIV] and the illusion that ‘those people who live over there do things that me and my kind don’t do’ is just garbage.”

That’s the PrEP stigma that the universal PrEP counseling in the guidelines is meant to override, said Dr. Daskalakis. Going forward, he said that informing people about PrEP should be treated as normally as counseling people about smoking.

“You can change the blank: You talk to all adolescents and adults about not smoking,” he said. “This is: ‘Tell adolescents and adults about ways you can prevent HIV, and PrEP is one of them.’ ”

The guidelines also simplify for monitoring lab levels for the current daily pills, checking creatinine clearance levels twice a year in people older than age 50 and once a year in those younger than 50 taking the oral pills. Dr. Daskalakis said that should ease the burden of monitoring PrEP patients for health care professionals with busy caseloads.

It’s a move that drew praise from Shawnika Hull, PhD, assistant professor of health communications at Rutgers University, New Brunswick, N.J.. Dr. Hull’s recent data showed that clinicians who espoused more biased racial views were also less likely to prescribe PrEP to Black women who asked for it.

“Public health practitioners and scientists have been advocating for this as a strategy, as one way to address several ongoing barriers to PrEP specifically but also equity in PrEP,” said Dr. Hull. “This sort of universal provision of information is really an important strategy to try to undo some of the deeply intertwined barriers to uptake.”
 

‘Don’t grill them’

The updated guidelines keep the number and proportion of Americans who could benefit from PrEP the same: 1.2 million Americans, with nearly half of those Black. And the reasons people would qualify for PrEP remain the same: inconsistent condom use, sharing injection drug equipment, and a STI diagnosis in the last 6 months. There are also 57 jurisdictions, including seven rural states, where dating and having sex carries an increased risk of acquiring HIV because of high rates of untreated HIV in the community.

That’s why the other big change in the update is guidance to prescribe PrEP to whoever asks for it, whether the patient divulges their risk or not. Or as Dr. Daskalakis puts it: “If someone asks for PrEP, don’t grill them.”

There are lots of reasons that someone might ask for PrEP without divulging their risk behaviors, said Dr. Daskalakis, who was an infectious disease doctor in New York back in 2012 (and a member of the FDA committee) when the first pill for PrEP was approved. He said he’s seen this particularly with women who ask about it. Asking for PrEP ends up being an “ice breaker” to discussing the woman’s sexual and injection drug use history, which can then improve the kinds of tests and vaccinations clinicians suggest for her.

“So many women will open the door and say, ‘I want to do this,’ and not necessarily want to go into the details,” he said. “Now, will they go into the details later? Absolutely. That’s how you create trust and connection.”
 

A mandate and a guideline

Leisha McKinley-Beach, MPH, a member of the U.S. Women and PrEP Working Group, has been urging greater funding and mandates to expand PrEP to women since the first pill was approved. And still, Ms. McKinley-Beach said she recently met a woman who worked for a community group scheduling PrEP appointments for gay men. But the woman didn’t know that she, too, could take it. 

The American Academy of Family Physicians recommends health care professionals offer PrEP to those who can benefit. The American College of Obstetricians and Gynecologists have a 2014 committee opinion stating that PrEP “may be a useful tool for women at highest risk of HIV acquisition.”

But the ACOG opinion is not a recommendation, stating that it “should not be construed as dictating an exclusive course of treatment or procedure to be followed.” Ms. McKinley-Beach said she hopes that the new CDC guidelines will prompt ACOG and other professional organizations to issue statements to include PrEP education in all health assessments. A spokesperson for ACOG said that the organization had not seen the new CDC guidelines and had no statement on them, but pointed out that the 2014 committee opinion is one of the “highest level of documents we produce.

“We have failed for nearly a decade to raise awareness that PrEP is also a prevention strategy for women,” Ms. McKinley-Beach said in an interview. “In many ways, we’re still back in 2012 as it relates to women.”

Dr. Hull reported having done previous research funded by Gilead Sciences and having received consulting fees from Gilead Sciences in 2018. Ms. McKinley-Beach reported receiving honoraria from ViiV Healthcare. Ms. Sherman and Dr. Daskalakis disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Starting Dec. 8, the Centers for Disease Control and Prevention recommends all clinicians talk to their sexually active adolescent and adult patients about HIV pre-exposure prophylaxis (PrEP) at least once and prescribe the prevention pills to anyone who asks for them, whether or not you understand their need for it.

“PrEP is a part of good primary care,” Demetre Daskalakis, MD, CDC’s director of the division of HIV/AIDS prevention, said in an interview. “Listening to people and what they need, as opposed to assessing what you think they need, is a seismic shift in how PrEP should be offered.”

The expanded recommendation comes as part of the 2021 update to the U.S. Public Health Service’s PrEP prescribing guidelines. It’s the third iteration since the Food and Drug Administration approved the first HIV prevention pill in 2012, and the first to include guidance on how to prescribe and monitor an injectable version of PrEP, which the FDA may approve as early as December 2021.

There are currently two pills, Truvada (emtricitabine/tenofovir disoproxil fumarate, Gilead Sciences and generic) and Descovy (emtricitabine/tenofovir alafenamide, Gilead Sciences). The pills have been found to be up to 99% effective in preventing HIV acquisition. The new injectable cabotegravir appears to be even more effective.

The broadened guidance is part of an effort from the country’s top health officials to expand PrEP prescribing from infectious disease specialists and sexual health clinics to health care professionals, including gynecologists, internal medicine physicians, and family practice clinicians. It appears to be necessary. In 2020, just 25% of the 1.2 million Americans who could benefit from PrEP were taking it, according to CDC data.

But those rates belie stark disparities in PrEP use by race and gender. The vast majority of those using PrEP are White Americans and men. About 66% of White Americans who could benefit from PrEP used it in 2020, and more than a quarter of the men who could benefit used it. By contrast, just 16% of Latinx people who could benefit had a prescription. And fewer than 1 in 10 Black Americans, who make up nearly half of those with indications for PrEP, had a prescription. The same was true for the women who could benefit.

Researchers and data from early PrEP demonstration projects have documented that clinicians are less likely to refer or prescribe the HIV prevention pills to Black people, especially the Black cisgender and transgender women and same-gender-loving men who bear the disproportionate burden of new cases in the United States, as well as fail to prescribe the medication to people who inject drugs.
 

Normalizing PrEP in primary care

When Courtney Sherman, DNP, APRN, first heard about PrEP in the early 2010s, she joked that her reaction was: “You’re ridiculous. You’re making that up. That’s not real.”

Ms. Sherman is now launching a tele-PrEP program from CAN Community Health, a nonprofit network of community health centers in southern Florida. The tele-PrEP program is meant to serve people in Florida and beyond, to increase access to the pill in areas with few health care professionals, or clinicians unwilling to prescribe it.

“When I go other places, I can’t do what I do for a living without getting some sort of bizarre comment or look,” she said. But the looks don’t just come from family, friends, or her children’s teachers. They come from colleagues, too. “What I’ve learned is that anybody – anybody – can be impacted [by HIV] and the illusion that ‘those people who live over there do things that me and my kind don’t do’ is just garbage.”

That’s the PrEP stigma that the universal PrEP counseling in the guidelines is meant to override, said Dr. Daskalakis. Going forward, he said that informing people about PrEP should be treated as normally as counseling people about smoking.

“You can change the blank: You talk to all adolescents and adults about not smoking,” he said. “This is: ‘Tell adolescents and adults about ways you can prevent HIV, and PrEP is one of them.’ ”

The guidelines also simplify for monitoring lab levels for the current daily pills, checking creatinine clearance levels twice a year in people older than age 50 and once a year in those younger than 50 taking the oral pills. Dr. Daskalakis said that should ease the burden of monitoring PrEP patients for health care professionals with busy caseloads.

It’s a move that drew praise from Shawnika Hull, PhD, assistant professor of health communications at Rutgers University, New Brunswick, N.J.. Dr. Hull’s recent data showed that clinicians who espoused more biased racial views were also less likely to prescribe PrEP to Black women who asked for it.

“Public health practitioners and scientists have been advocating for this as a strategy, as one way to address several ongoing barriers to PrEP specifically but also equity in PrEP,” said Dr. Hull. “This sort of universal provision of information is really an important strategy to try to undo some of the deeply intertwined barriers to uptake.”
 

‘Don’t grill them’

The updated guidelines keep the number and proportion of Americans who could benefit from PrEP the same: 1.2 million Americans, with nearly half of those Black. And the reasons people would qualify for PrEP remain the same: inconsistent condom use, sharing injection drug equipment, and a STI diagnosis in the last 6 months. There are also 57 jurisdictions, including seven rural states, where dating and having sex carries an increased risk of acquiring HIV because of high rates of untreated HIV in the community.

That’s why the other big change in the update is guidance to prescribe PrEP to whoever asks for it, whether the patient divulges their risk or not. Or as Dr. Daskalakis puts it: “If someone asks for PrEP, don’t grill them.”

There are lots of reasons that someone might ask for PrEP without divulging their risk behaviors, said Dr. Daskalakis, who was an infectious disease doctor in New York back in 2012 (and a member of the FDA committee) when the first pill for PrEP was approved. He said he’s seen this particularly with women who ask about it. Asking for PrEP ends up being an “ice breaker” to discussing the woman’s sexual and injection drug use history, which can then improve the kinds of tests and vaccinations clinicians suggest for her.

“So many women will open the door and say, ‘I want to do this,’ and not necessarily want to go into the details,” he said. “Now, will they go into the details later? Absolutely. That’s how you create trust and connection.”
 

A mandate and a guideline

Leisha McKinley-Beach, MPH, a member of the U.S. Women and PrEP Working Group, has been urging greater funding and mandates to expand PrEP to women since the first pill was approved. And still, Ms. McKinley-Beach said she recently met a woman who worked for a community group scheduling PrEP appointments for gay men. But the woman didn’t know that she, too, could take it. 

The American Academy of Family Physicians recommends health care professionals offer PrEP to those who can benefit. The American College of Obstetricians and Gynecologists have a 2014 committee opinion stating that PrEP “may be a useful tool for women at highest risk of HIV acquisition.”

But the ACOG opinion is not a recommendation, stating that it “should not be construed as dictating an exclusive course of treatment or procedure to be followed.” Ms. McKinley-Beach said she hopes that the new CDC guidelines will prompt ACOG and other professional organizations to issue statements to include PrEP education in all health assessments. A spokesperson for ACOG said that the organization had not seen the new CDC guidelines and had no statement on them, but pointed out that the 2014 committee opinion is one of the “highest level of documents we produce.

“We have failed for nearly a decade to raise awareness that PrEP is also a prevention strategy for women,” Ms. McKinley-Beach said in an interview. “In many ways, we’re still back in 2012 as it relates to women.”

Dr. Hull reported having done previous research funded by Gilead Sciences and having received consulting fees from Gilead Sciences in 2018. Ms. McKinley-Beach reported receiving honoraria from ViiV Healthcare. Ms. Sherman and Dr. Daskalakis disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Starting Dec. 8, the Centers for Disease Control and Prevention recommends all clinicians talk to their sexually active adolescent and adult patients about HIV pre-exposure prophylaxis (PrEP) at least once and prescribe the prevention pills to anyone who asks for them, whether or not you understand their need for it.

“PrEP is a part of good primary care,” Demetre Daskalakis, MD, CDC’s director of the division of HIV/AIDS prevention, said in an interview. “Listening to people and what they need, as opposed to assessing what you think they need, is a seismic shift in how PrEP should be offered.”

The expanded recommendation comes as part of the 2021 update to the U.S. Public Health Service’s PrEP prescribing guidelines. It’s the third iteration since the Food and Drug Administration approved the first HIV prevention pill in 2012, and the first to include guidance on how to prescribe and monitor an injectable version of PrEP, which the FDA may approve as early as December 2021.

There are currently two pills, Truvada (emtricitabine/tenofovir disoproxil fumarate, Gilead Sciences and generic) and Descovy (emtricitabine/tenofovir alafenamide, Gilead Sciences). The pills have been found to be up to 99% effective in preventing HIV acquisition. The new injectable cabotegravir appears to be even more effective.

The broadened guidance is part of an effort from the country’s top health officials to expand PrEP prescribing from infectious disease specialists and sexual health clinics to health care professionals, including gynecologists, internal medicine physicians, and family practice clinicians. It appears to be necessary. In 2020, just 25% of the 1.2 million Americans who could benefit from PrEP were taking it, according to CDC data.

But those rates belie stark disparities in PrEP use by race and gender. The vast majority of those using PrEP are White Americans and men. About 66% of White Americans who could benefit from PrEP used it in 2020, and more than a quarter of the men who could benefit used it. By contrast, just 16% of Latinx people who could benefit had a prescription. And fewer than 1 in 10 Black Americans, who make up nearly half of those with indications for PrEP, had a prescription. The same was true for the women who could benefit.

Researchers and data from early PrEP demonstration projects have documented that clinicians are less likely to refer or prescribe the HIV prevention pills to Black people, especially the Black cisgender and transgender women and same-gender-loving men who bear the disproportionate burden of new cases in the United States, as well as fail to prescribe the medication to people who inject drugs.
 

Normalizing PrEP in primary care

When Courtney Sherman, DNP, APRN, first heard about PrEP in the early 2010s, she joked that her reaction was: “You’re ridiculous. You’re making that up. That’s not real.”

Ms. Sherman is now launching a tele-PrEP program from CAN Community Health, a nonprofit network of community health centers in southern Florida. The tele-PrEP program is meant to serve people in Florida and beyond, to increase access to the pill in areas with few health care professionals, or clinicians unwilling to prescribe it.

“When I go other places, I can’t do what I do for a living without getting some sort of bizarre comment or look,” she said. But the looks don’t just come from family, friends, or her children’s teachers. They come from colleagues, too. “What I’ve learned is that anybody – anybody – can be impacted [by HIV] and the illusion that ‘those people who live over there do things that me and my kind don’t do’ is just garbage.”

That’s the PrEP stigma that the universal PrEP counseling in the guidelines is meant to override, said Dr. Daskalakis. Going forward, he said that informing people about PrEP should be treated as normally as counseling people about smoking.

“You can change the blank: You talk to all adolescents and adults about not smoking,” he said. “This is: ‘Tell adolescents and adults about ways you can prevent HIV, and PrEP is one of them.’ ”

The guidelines also simplify for monitoring lab levels for the current daily pills, checking creatinine clearance levels twice a year in people older than age 50 and once a year in those younger than 50 taking the oral pills. Dr. Daskalakis said that should ease the burden of monitoring PrEP patients for health care professionals with busy caseloads.

It’s a move that drew praise from Shawnika Hull, PhD, assistant professor of health communications at Rutgers University, New Brunswick, N.J.. Dr. Hull’s recent data showed that clinicians who espoused more biased racial views were also less likely to prescribe PrEP to Black women who asked for it.

“Public health practitioners and scientists have been advocating for this as a strategy, as one way to address several ongoing barriers to PrEP specifically but also equity in PrEP,” said Dr. Hull. “This sort of universal provision of information is really an important strategy to try to undo some of the deeply intertwined barriers to uptake.”
 

‘Don’t grill them’

The updated guidelines keep the number and proportion of Americans who could benefit from PrEP the same: 1.2 million Americans, with nearly half of those Black. And the reasons people would qualify for PrEP remain the same: inconsistent condom use, sharing injection drug equipment, and a STI diagnosis in the last 6 months. There are also 57 jurisdictions, including seven rural states, where dating and having sex carries an increased risk of acquiring HIV because of high rates of untreated HIV in the community.

That’s why the other big change in the update is guidance to prescribe PrEP to whoever asks for it, whether the patient divulges their risk or not. Or as Dr. Daskalakis puts it: “If someone asks for PrEP, don’t grill them.”

There are lots of reasons that someone might ask for PrEP without divulging their risk behaviors, said Dr. Daskalakis, who was an infectious disease doctor in New York back in 2012 (and a member of the FDA committee) when the first pill for PrEP was approved. He said he’s seen this particularly with women who ask about it. Asking for PrEP ends up being an “ice breaker” to discussing the woman’s sexual and injection drug use history, which can then improve the kinds of tests and vaccinations clinicians suggest for her.

“So many women will open the door and say, ‘I want to do this,’ and not necessarily want to go into the details,” he said. “Now, will they go into the details later? Absolutely. That’s how you create trust and connection.”
 

A mandate and a guideline

Leisha McKinley-Beach, MPH, a member of the U.S. Women and PrEP Working Group, has been urging greater funding and mandates to expand PrEP to women since the first pill was approved. And still, Ms. McKinley-Beach said she recently met a woman who worked for a community group scheduling PrEP appointments for gay men. But the woman didn’t know that she, too, could take it. 

The American Academy of Family Physicians recommends health care professionals offer PrEP to those who can benefit. The American College of Obstetricians and Gynecologists have a 2014 committee opinion stating that PrEP “may be a useful tool for women at highest risk of HIV acquisition.”

But the ACOG opinion is not a recommendation, stating that it “should not be construed as dictating an exclusive course of treatment or procedure to be followed.” Ms. McKinley-Beach said she hopes that the new CDC guidelines will prompt ACOG and other professional organizations to issue statements to include PrEP education in all health assessments. A spokesperson for ACOG said that the organization had not seen the new CDC guidelines and had no statement on them, but pointed out that the 2014 committee opinion is one of the “highest level of documents we produce.

“We have failed for nearly a decade to raise awareness that PrEP is also a prevention strategy for women,” Ms. McKinley-Beach said in an interview. “In many ways, we’re still back in 2012 as it relates to women.”

Dr. Hull reported having done previous research funded by Gilead Sciences and having received consulting fees from Gilead Sciences in 2018. Ms. McKinley-Beach reported receiving honoraria from ViiV Healthcare. Ms. Sherman and Dr. Daskalakis disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Decades before becoming the go-to authority in the United States on the COVID-19 global pandemic, Anthony S. Fauci, MD, found himself witnessing the earliest perplexing cases of what would become another devastating global pandemic – HIV/AIDS. And while extraordinary advances have transformed treatment and prevention, glaring treatment gaps and challenges remain after 40 years.

“I certainly remember those initial MMWRs [the Morbidity and Mortality Weekly Reports] in the summer of 1981 that introduced us to what would turn out to be the most extraordinary and devastating pandemic of an infectious disease up until that time in the modern era,” said Dr. Fauci when addressing the 2021 United States Conference on HIV/AIDS.

“Now, 40 years into it, we are still in the middle of a global pandemic despite the fact that there have been extraordinary advances,” said Dr. Fauci, who is director of the National Institute of Allergy and Infectious Diseases and chief medical advisor to the President of the United States.

Specifically, it was on June 5, 1981, that the Centers for Disease Control and Prevention issued its fateful report on the first five cases of what would soon become known as Acquired Immune Deficiency Syndrome.

By 2020, the 5 cases had grown to 79.3 million HIV infections since the start of the HIV/AIDS pandemic, claiming 36.3 million lives, according to the NAIDS Global AIDS update, Dr. Fauci reported.

At the end of 2020, there were 1.5 million new infections, as many as 37.7 million people living with HIV, and 680,000 deaths, according to the report.

The fact that so many people are living with HIV – and not dying from it – is largely attributable to “breathtaking” advances in treatment, Dr. Fauci said, underscoring the fact that there are now 13 single-tablet, once-daily, antiretroviral (ART) regimens approved in the United States to replace the multidrug cocktail that has long been necessary with HIV treatment.

“I can remember when the combination therapies were first made available, we were giving patients literally dozens of pills of different types each day, but that is no longer the case,” Dr. Fauci said.

“We can say, without hyperbole, that highly effective antiretroviral therapy for HIV is indeed one of the most important biomedical research advances of our era.”

Furthermore, HIV prevention using pre-exposure prophylaxis (PrEP), when used optimally and consistently, has further transformed the HIV landscape with 99% efficacy in preventing sexual HIV acquisition.
 

Troubling treatment gaps

Despite the advances, disparities and challenges are abundant, Dr. Fauci said.

Notably, the majority of those infected globally – 65% – are concentrated among key populations, including gay men and other men who have sex with men (23%), clients of sex workers (20%), sex workers (11%), people who inject drugs (9%), and transgender people (2%), according to the Joint United Nations Programme on HIV/AIDS.

According to UNAIDS, among the 37.7 million people living with HIV at the end of 2020, 27.5 million were being treated with life-saving ART, leaving a gap of 10.2 million people with HIV who are not receiving the treatment, Dr. Fauci pointed out.

And of those who do receive treatment, retention is suboptimal, with only about 65% of patients in low- and middle-income countries being retained in care at 48 months following ART initiation.

Dr. Fauci underscored encouraging developments that could address some of those problems, notably long-acting ART therapies that, in requiring administration only every 6 months or so, could negate the need for adherence to daily ART therapy.

Likewise, long-acting PrEP provided intermittently over longer periods could prevent transmission.

“We’re looking at [long-acting PrEP] with a great deal of enthusiasm as providing protection with longer durations between doses to get people to essentially have close to 99% protection against HIV acquisition,” Dr. Fauci said.

While several efforts to develop vaccines for HIV in long-term clinical trials have had disappointing results, Dr. Fauci says he stops short of calling them failures.

“We don’t consider the trials to be failures because, in fact, they tell us the way we need to go – which direction,” he said.

“In fact, COVID-19 itself has given us new enthusiasm about the use of vaccine platforms such as mRNA that are now being applied in the vaccine quest for HIV,” Dr. Fauci noted.

Ultimately, “we must steadily and steadfastly move forward to address critical research gaps and unanswered questions [regarding HIV],” Dr. Fauci said. “The scientific advances have been breathtaking and it is up to us to [achieve] greater scientific advances, but also to translate them into something that can be implemented.”

USCHA Executive Director Paul Kawata, MD, commented that he shares Dr. Fauci’s optimism — and his concerns.

“NMAC [formerly the National Minority AIDS Council, which runs USCHA] is very excited about the science,” he said in an interview. “Our ability to make treatment easier should be a pathway to success.”

“Our concern is that we need more implementation science to know if long-acting ART will be used by the communities hardest hit by HIV,” he said.

Dr. Kawata noted that NMAC agrees that vaccine trial “failures” can offer important lessons, “but we are getting impatient,” he said. “Back in the 80s, Secretary Margret Heckler said we would have a vaccine in 5 years.”

Furthermore, ongoing racial disparities, left unaddressed, will hold back meaningful progress in the fight against HIV, he noted. “We are always hopeful, [but] the reality is that race and racism play an outsized role in health outcome in America. Unless we address these inequalities, we will never end HIV.”

NMAC receives funding from Gilead, Viiv, Merck, and Janssen.

A version of this article first appeared on Medscape.com.

Decades before becoming the go-to authority in the United States on the COVID-19 global pandemic, Anthony S. Fauci, MD, found himself witnessing the earliest perplexing cases of what would become another devastating global pandemic – HIV/AIDS. And while extraordinary advances have transformed treatment and prevention, glaring treatment gaps and challenges remain after 40 years.

“I certainly remember those initial MMWRs [the Morbidity and Mortality Weekly Reports] in the summer of 1981 that introduced us to what would turn out to be the most extraordinary and devastating pandemic of an infectious disease up until that time in the modern era,” said Dr. Fauci when addressing the 2021 United States Conference on HIV/AIDS.

“Now, 40 years into it, we are still in the middle of a global pandemic despite the fact that there have been extraordinary advances,” said Dr. Fauci, who is director of the National Institute of Allergy and Infectious Diseases and chief medical advisor to the President of the United States.

Specifically, it was on June 5, 1981, that the Centers for Disease Control and Prevention issued its fateful report on the first five cases of what would soon become known as Acquired Immune Deficiency Syndrome.

By 2020, the 5 cases had grown to 79.3 million HIV infections since the start of the HIV/AIDS pandemic, claiming 36.3 million lives, according to the NAIDS Global AIDS update, Dr. Fauci reported.

At the end of 2020, there were 1.5 million new infections, as many as 37.7 million people living with HIV, and 680,000 deaths, according to the report.

The fact that so many people are living with HIV – and not dying from it – is largely attributable to “breathtaking” advances in treatment, Dr. Fauci said, underscoring the fact that there are now 13 single-tablet, once-daily, antiretroviral (ART) regimens approved in the United States to replace the multidrug cocktail that has long been necessary with HIV treatment.

“I can remember when the combination therapies were first made available, we were giving patients literally dozens of pills of different types each day, but that is no longer the case,” Dr. Fauci said.

“We can say, without hyperbole, that highly effective antiretroviral therapy for HIV is indeed one of the most important biomedical research advances of our era.”

Furthermore, HIV prevention using pre-exposure prophylaxis (PrEP), when used optimally and consistently, has further transformed the HIV landscape with 99% efficacy in preventing sexual HIV acquisition.
 

Troubling treatment gaps

Despite the advances, disparities and challenges are abundant, Dr. Fauci said.

Notably, the majority of those infected globally – 65% – are concentrated among key populations, including gay men and other men who have sex with men (23%), clients of sex workers (20%), sex workers (11%), people who inject drugs (9%), and transgender people (2%), according to the Joint United Nations Programme on HIV/AIDS.

According to UNAIDS, among the 37.7 million people living with HIV at the end of 2020, 27.5 million were being treated with life-saving ART, leaving a gap of 10.2 million people with HIV who are not receiving the treatment, Dr. Fauci pointed out.

And of those who do receive treatment, retention is suboptimal, with only about 65% of patients in low- and middle-income countries being retained in care at 48 months following ART initiation.

Dr. Fauci underscored encouraging developments that could address some of those problems, notably long-acting ART therapies that, in requiring administration only every 6 months or so, could negate the need for adherence to daily ART therapy.

Likewise, long-acting PrEP provided intermittently over longer periods could prevent transmission.

“We’re looking at [long-acting PrEP] with a great deal of enthusiasm as providing protection with longer durations between doses to get people to essentially have close to 99% protection against HIV acquisition,” Dr. Fauci said.

While several efforts to develop vaccines for HIV in long-term clinical trials have had disappointing results, Dr. Fauci says he stops short of calling them failures.

“We don’t consider the trials to be failures because, in fact, they tell us the way we need to go – which direction,” he said.

“In fact, COVID-19 itself has given us new enthusiasm about the use of vaccine platforms such as mRNA that are now being applied in the vaccine quest for HIV,” Dr. Fauci noted.

Ultimately, “we must steadily and steadfastly move forward to address critical research gaps and unanswered questions [regarding HIV],” Dr. Fauci said. “The scientific advances have been breathtaking and it is up to us to [achieve] greater scientific advances, but also to translate them into something that can be implemented.”

USCHA Executive Director Paul Kawata, MD, commented that he shares Dr. Fauci’s optimism — and his concerns.

“NMAC [formerly the National Minority AIDS Council, which runs USCHA] is very excited about the science,” he said in an interview. “Our ability to make treatment easier should be a pathway to success.”

“Our concern is that we need more implementation science to know if long-acting ART will be used by the communities hardest hit by HIV,” he said.

Dr. Kawata noted that NMAC agrees that vaccine trial “failures” can offer important lessons, “but we are getting impatient,” he said. “Back in the 80s, Secretary Margret Heckler said we would have a vaccine in 5 years.”

Furthermore, ongoing racial disparities, left unaddressed, will hold back meaningful progress in the fight against HIV, he noted. “We are always hopeful, [but] the reality is that race and racism play an outsized role in health outcome in America. Unless we address these inequalities, we will never end HIV.”

NMAC receives funding from Gilead, Viiv, Merck, and Janssen.

A version of this article first appeared on Medscape.com.

Decades before becoming the go-to authority in the United States on the COVID-19 global pandemic, Anthony S. Fauci, MD, found himself witnessing the earliest perplexing cases of what would become another devastating global pandemic – HIV/AIDS. And while extraordinary advances have transformed treatment and prevention, glaring treatment gaps and challenges remain after 40 years.

“I certainly remember those initial MMWRs [the Morbidity and Mortality Weekly Reports] in the summer of 1981 that introduced us to what would turn out to be the most extraordinary and devastating pandemic of an infectious disease up until that time in the modern era,” said Dr. Fauci when addressing the 2021 United States Conference on HIV/AIDS.

“Now, 40 years into it, we are still in the middle of a global pandemic despite the fact that there have been extraordinary advances,” said Dr. Fauci, who is director of the National Institute of Allergy and Infectious Diseases and chief medical advisor to the President of the United States.

Specifically, it was on June 5, 1981, that the Centers for Disease Control and Prevention issued its fateful report on the first five cases of what would soon become known as Acquired Immune Deficiency Syndrome.

By 2020, the 5 cases had grown to 79.3 million HIV infections since the start of the HIV/AIDS pandemic, claiming 36.3 million lives, according to the NAIDS Global AIDS update, Dr. Fauci reported.

At the end of 2020, there were 1.5 million new infections, as many as 37.7 million people living with HIV, and 680,000 deaths, according to the report.

The fact that so many people are living with HIV – and not dying from it – is largely attributable to “breathtaking” advances in treatment, Dr. Fauci said, underscoring the fact that there are now 13 single-tablet, once-daily, antiretroviral (ART) regimens approved in the United States to replace the multidrug cocktail that has long been necessary with HIV treatment.

“I can remember when the combination therapies were first made available, we were giving patients literally dozens of pills of different types each day, but that is no longer the case,” Dr. Fauci said.

“We can say, without hyperbole, that highly effective antiretroviral therapy for HIV is indeed one of the most important biomedical research advances of our era.”

Furthermore, HIV prevention using pre-exposure prophylaxis (PrEP), when used optimally and consistently, has further transformed the HIV landscape with 99% efficacy in preventing sexual HIV acquisition.
 

Troubling treatment gaps

Despite the advances, disparities and challenges are abundant, Dr. Fauci said.

Notably, the majority of those infected globally – 65% – are concentrated among key populations, including gay men and other men who have sex with men (23%), clients of sex workers (20%), sex workers (11%), people who inject drugs (9%), and transgender people (2%), according to the Joint United Nations Programme on HIV/AIDS.

According to UNAIDS, among the 37.7 million people living with HIV at the end of 2020, 27.5 million were being treated with life-saving ART, leaving a gap of 10.2 million people with HIV who are not receiving the treatment, Dr. Fauci pointed out.

And of those who do receive treatment, retention is suboptimal, with only about 65% of patients in low- and middle-income countries being retained in care at 48 months following ART initiation.

Dr. Fauci underscored encouraging developments that could address some of those problems, notably long-acting ART therapies that, in requiring administration only every 6 months or so, could negate the need for adherence to daily ART therapy.

Likewise, long-acting PrEP provided intermittently over longer periods could prevent transmission.

“We’re looking at [long-acting PrEP] with a great deal of enthusiasm as providing protection with longer durations between doses to get people to essentially have close to 99% protection against HIV acquisition,” Dr. Fauci said.

While several efforts to develop vaccines for HIV in long-term clinical trials have had disappointing results, Dr. Fauci says he stops short of calling them failures.

“We don’t consider the trials to be failures because, in fact, they tell us the way we need to go – which direction,” he said.

“In fact, COVID-19 itself has given us new enthusiasm about the use of vaccine platforms such as mRNA that are now being applied in the vaccine quest for HIV,” Dr. Fauci noted.

Ultimately, “we must steadily and steadfastly move forward to address critical research gaps and unanswered questions [regarding HIV],” Dr. Fauci said. “The scientific advances have been breathtaking and it is up to us to [achieve] greater scientific advances, but also to translate them into something that can be implemented.”

USCHA Executive Director Paul Kawata, MD, commented that he shares Dr. Fauci’s optimism — and his concerns.

“NMAC [formerly the National Minority AIDS Council, which runs USCHA] is very excited about the science,” he said in an interview. “Our ability to make treatment easier should be a pathway to success.”

“Our concern is that we need more implementation science to know if long-acting ART will be used by the communities hardest hit by HIV,” he said.

Dr. Kawata noted that NMAC agrees that vaccine trial “failures” can offer important lessons, “but we are getting impatient,” he said. “Back in the 80s, Secretary Margret Heckler said we would have a vaccine in 5 years.”

Furthermore, ongoing racial disparities, left unaddressed, will hold back meaningful progress in the fight against HIV, he noted. “We are always hopeful, [but] the reality is that race and racism play an outsized role in health outcome in America. Unless we address these inequalities, we will never end HIV.”

NMAC receives funding from Gilead, Viiv, Merck, and Janssen.

A version of this article first appeared on Medscape.com.

Not that long ago, a man in his mid-20s whom Morgan Farrington calls Kiddo showed up at her house with a fever, chills, and nausea. He was increasingly out of it. These were all signs of an abscess from missing a vein and using someone else’s syringe, said Farrington, founder of Goodworks, in Huntsville, Alabama.

But it wasn’t just an abscess. It was four blood clots and sepsis. He’d been craving his next fix of heroin so hard, and the relief that comes from the act of shooting up itself, that he’d dug a 3-day-old blood shot – a used syringe with someone else’s blood in it – out of the garbage and had used it.

“He was almost dead,” said Farrington. “Another day, maybe two, he would have been dead, for sure, for sure.”

Farrington gets it. She has her own history of injection drug use. She knows the compulsion to, in her words, “shoot up sugar water just to get a hit.” And that’s fine, she said. “I just wish that he would do so with his own safety in mind.”

So when he got out of the hospital a few weeks later, Farrington talked to him about not just clean syringes but also HIV pre-exposure prophylaxis (PrEP), the daily HIV prevention pills that have been found to be up to 84% protective against HIV in people who inject drugs. Both approaches – syringe services and PrEP – play a key role in the president’s new National HIV/AIDS Strategy. The strategy calls for expanding access to both services in traditional and nontraditional settings but doesn’t include mechanisms for that to happen.

Of the 1.2 million people in the U.S. who could benefit from PrEP, according to the Centers for Disease Control and Prevention, 23% are using it. But according to data published in 2020, just 0% and 5% of people who inject drugs who could benefit are using it. And most, like the guy Farrington continues to talk to, don’t even know it exists.
 

People who inject drugs are willing, clinicians may not be

Clinicians have a role to play, but right now, many clinicians act as gatekeepers, picking and choosing whom they’ll offer PrEP to. In 2014, just 1% of PrEP prescribers said they had prescribed the prevention pill to people who inject drugs. And recent data published in AIDS and Behavior showed that clinicians who expressed negative attitudes about people who injected drugs were less likely to offer to prescribe PrEP to a theoretical man who injected drugs asking for PrEP. There was a paradox in there, however: Clinicians were also more likely to think men who inject drugs were at high risk for acquiring HIV. But they also believed those men would be less likely to adhere, less safety conscious, and less responsible than gay and bisexual men. So, the investigators found that despite need, clinicians were more likely to prescribe to men at risk via sex than men at risk via injection drug use.

According to the CDC, to qualify for PrEP, the only requirements for people who inject drugs are testing negative for HIV and not sharing injection equipment – whether their injecting partners have confirmed HIV or whether their HIV status is unknown.

“As long as PrEP is a prescription, medication providers are really going to determine who accesses PrEP and who does not,” said study lead author Sarah Calabrese, PhD, assistant professor of psychiatry at George Washington University. “Even if you do anticipate that a patient might have adherence struggles. The solution is not withholding something that could be beneficial to them. The solution is supporting them to take that beneficial medication.”

And it appears that providers and regular people like Farrington have stepped into the access vacuum, with a decidedly harm-reduction approach: syringe services programs. While there’s no national data on how many people receive PrEP through needle exchange programs, those programs are the natural place to offer other health care services, said Hansel Tookes, MD, assistant professor of medicine at the University of Miami and founder of the Infectious Disease Elimination Act (IDEA) Syringe Exchange program and clinic. At the clinic, 80% of the people living with HIV have undetectable viral loads – a sign of good adherence to medication and general health. Previous research suggests that when people who inject drugs find out about PrEP, 57% are game for trying it. But early work suggests that people who inject drugs might need to access PrEP in a different way from other people who use PrEP.

Dr. Tookes is currently conducting a study looking at whether referring people who inject drugs out from needle exchanges to PrEP prescribers is as effective as offering it on site at the exchanges.

“My experience in the past 5 years of being faculty at the university and being a cofounder of a program like IDEA is that we really, if we’re going to be successful with engaging people who inject drugs in things like PrEP, we have to, like all things harm reduction, meet them where they’re at, both physically and mentally, and on their own terms,” said Dr. Tookes. “What better place than a syringe services program?”
 

Where people are: the exchanges

That’s where community health worker Farrington and others come in. More than 400 syringe access programs that exist in North America have PrEP programs, according to the North American Syringe Exchange Network (NASEN), and 86 of them report offering access to PrEP, either directly or through referrals. It’s an HIV prevention one-two punch: PrEP protects a person once they are exposed to HIV, and needle exchanges themselves reduce HIV transmission rates by reducing the odds that people will engage in behavior that exposes them to the virus in the first place.

So far, PrEP access for people who inject drugs looks different everywhere. At Las Vegas’ Huntridge Family Clinic, people can come to the lobby and pick up clean supplies from a syringe exchange vending machine, and while they’re there, talk to nurse practitioner Rob Phoenix, MSN, APRN, about HIV prevention.

In Cincinnati, where Adam Reilly, CDCA, runs a Ryan White–funded PrEP program out of the nonprofit Caracole, PrEP navigators go out with the syringe services vans run by the county health department and can connect them with providers willing to prescribe it. In Alabama, where needle exchanges are illegal, Farrington works as a community health worker through the North Alabama Area Health Education Center to go in to Huntsville’s legal tent cities to offer HIV and hepatitis C testing and tell them about PrEP. In Philadelphia, Drexel University, the city Department of Health, and Prevention Point Philadelphia co-offer PrEP through Prevention Point, which increased the number of people who inject drugs taking PrEP from just two to three a year to 584 times in 2021, according to Andres Freire, director of harm reduction health services at Prevention Point Philadelphia.

“Co-locating a PrEP clinic with our syringe-services program is the most effective means of delivering care to people who use drugs,” he said. “It is a friendly, nonstigmatizing place, as well as a place where individuals are already coming for services.”

At Dr. Tookes’ IDEA clinic and its PrEP study, people who inject drugs can not only get clean supplies, they can get a PrEP prescription on site and store their medications at the exchange so they don’t get stolen or used by others. And that idea didn’t come from him.

“It was one of my patients,” he said. “That person gave me an idea that impacted the health of hundreds of people in Miami.”

Indeed, Boston Health Care for the Homeless Program does the same. New data showed that what really worked for people who injected drugs in the group was not just medication storage on site but also PrEP prescriptions that lasted just a week at a time, or even same-day prescribing, as well as the program’s PrEP nurses showing up in person to their communities. That program managed to get PrEP referrals to 239 people, 152 of whom started taking PrEP. Six months later, 22 people were still using it.

But Dr. Tookes’s is a rare study on PrEP among people who inject drugs. The only data so far on the efficacy of PrEP for this group come from a 2013 study out of Thailand. Angela Bazzi, PhD, an associate professor of family medicine and public health at the University of California, San Diego, who studied the Boston program, said the dearth of research into effective ways of getting PrEP to people who inject drugs is fueling a negative feedback loop, where people who inject drugs and their providers largely don’t know about the HIV prevention pills, don’t see research on it, and therefore think it won’t work in people who inject drugs.

“There’s been a systematic exclusion of people who inject drugs from HIV prevention drug trials,” Dr. Bazzi told this news organization. Together with colleagues she wrote a viewpoint on the issue that was published in the International Journal of Drug Policy. “It really extends into effectiveness research, public health research, and clinical practice. We argued that the stigma surrounding addiction is the key driver of this.”

This is especially important, she said, because the U.S. Food and Drug Administration had been expected to make an approval decision on an injectable form of PrEP by Jan. 2021. That drug, cabotegravir, has been found to work for a month at a time. Injection drug users were excluded from the primary clinical trial of that drug, though a ViiV Healthcare spokesperson said the company is planning an after-market study in people who inject drugs some time in the future.
 

An incomplete solution

But syringe services aren’t enough, said Mr. Reilly. For one thing, public funding of PrEP programs can limit things like where navigators can send people. For instance, in Ohio, Mr. Reilly’s team can cover the costs of PrEP for people who inject drugs – but only with certain providers. State law prohibits them from contracting with Planned Parenthood.

Also, syringe services aren’t available everywhere. In Pennsylvania, where syringe services are legal only in the counties containing Philadelphia and Pittsburgh, the state’s two large cities, funding for basic syringe services precludes expanding services to offer PrEP.

“A lot of our focus has to stay with making sure our folks have access to the harm-reduction supplies they need, because the number of people we are seeing has grown exponentially during the pandemic,” said Katie Houston, a coordinator for Prevention Point Pittsburgh, which tries to address its clients’s PrEP needs by holding syringe-services distribution at a local clinic that provides PrEP. “Getting funding for our core supplies like syringes, crack pipes, and the works is extremely difficult because many grants/foundations don’t want to fund these supplies. And with the growing number of SSPs, the funding that has been available is being spread thin.”

And that means that traditional clinicians still have an important role to play, said Mr. Reilly.

“Syringe services programs are supposed to now provide treatment for hepatitis C and make sure people get on PrEP?” he said. “That seems like medical providers’s job.”

As for Farrington, operating as a solo health worker without the benefit of exchanges to help people like the young man who came to her house that night, she’ll keep going in to tent city and inviting sick people who inject drugs into her home to offer them what she can. She can’t legally offer syringe services. But she can keep checking in on people and offering them the help that’s available.

Recently, she saw that young man again. He was in a better place. He had found a place to live for the winter, so he wouldn’t have to stay in the hammock in someone’s yard when the temperatures dipped. And that was going a long way to stabilize everything else in his life. He’s still shooting up, she said, but having housing is making it easier for him to moderate his use. As for PrEP, he hasn’t started on that, either. But Farrington hasn’t given up hope.

“Not yet,” she said.

Dr. Tookes reports receiving research funding from Gilead Sciences. Dr. Calabrese reports receiving conference travel funding from Gilead Sciences. Farrington, Dr. Bazzi, Ms. Houston, Mr. Freire, and Mr. Reilly reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Not that long ago, a man in his mid-20s whom Morgan Farrington calls Kiddo showed up at her house with a fever, chills, and nausea. He was increasingly out of it. These were all signs of an abscess from missing a vein and using someone else’s syringe, said Farrington, founder of Goodworks, in Huntsville, Alabama.

But it wasn’t just an abscess. It was four blood clots and sepsis. He’d been craving his next fix of heroin so hard, and the relief that comes from the act of shooting up itself, that he’d dug a 3-day-old blood shot – a used syringe with someone else’s blood in it – out of the garbage and had used it.

“He was almost dead,” said Farrington. “Another day, maybe two, he would have been dead, for sure, for sure.”

Farrington gets it. She has her own history of injection drug use. She knows the compulsion to, in her words, “shoot up sugar water just to get a hit.” And that’s fine, she said. “I just wish that he would do so with his own safety in mind.”

So when he got out of the hospital a few weeks later, Farrington talked to him about not just clean syringes but also HIV pre-exposure prophylaxis (PrEP), the daily HIV prevention pills that have been found to be up to 84% protective against HIV in people who inject drugs. Both approaches – syringe services and PrEP – play a key role in the president’s new National HIV/AIDS Strategy. The strategy calls for expanding access to both services in traditional and nontraditional settings but doesn’t include mechanisms for that to happen.

Of the 1.2 million people in the U.S. who could benefit from PrEP, according to the Centers for Disease Control and Prevention, 23% are using it. But according to data published in 2020, just 0% and 5% of people who inject drugs who could benefit are using it. And most, like the guy Farrington continues to talk to, don’t even know it exists.
 

People who inject drugs are willing, clinicians may not be

Clinicians have a role to play, but right now, many clinicians act as gatekeepers, picking and choosing whom they’ll offer PrEP to. In 2014, just 1% of PrEP prescribers said they had prescribed the prevention pill to people who inject drugs. And recent data published in AIDS and Behavior showed that clinicians who expressed negative attitudes about people who injected drugs were less likely to offer to prescribe PrEP to a theoretical man who injected drugs asking for PrEP. There was a paradox in there, however: Clinicians were also more likely to think men who inject drugs were at high risk for acquiring HIV. But they also believed those men would be less likely to adhere, less safety conscious, and less responsible than gay and bisexual men. So, the investigators found that despite need, clinicians were more likely to prescribe to men at risk via sex than men at risk via injection drug use.

According to the CDC, to qualify for PrEP, the only requirements for people who inject drugs are testing negative for HIV and not sharing injection equipment – whether their injecting partners have confirmed HIV or whether their HIV status is unknown.

“As long as PrEP is a prescription, medication providers are really going to determine who accesses PrEP and who does not,” said study lead author Sarah Calabrese, PhD, assistant professor of psychiatry at George Washington University. “Even if you do anticipate that a patient might have adherence struggles. The solution is not withholding something that could be beneficial to them. The solution is supporting them to take that beneficial medication.”

And it appears that providers and regular people like Farrington have stepped into the access vacuum, with a decidedly harm-reduction approach: syringe services programs. While there’s no national data on how many people receive PrEP through needle exchange programs, those programs are the natural place to offer other health care services, said Hansel Tookes, MD, assistant professor of medicine at the University of Miami and founder of the Infectious Disease Elimination Act (IDEA) Syringe Exchange program and clinic. At the clinic, 80% of the people living with HIV have undetectable viral loads – a sign of good adherence to medication and general health. Previous research suggests that when people who inject drugs find out about PrEP, 57% are game for trying it. But early work suggests that people who inject drugs might need to access PrEP in a different way from other people who use PrEP.

Dr. Tookes is currently conducting a study looking at whether referring people who inject drugs out from needle exchanges to PrEP prescribers is as effective as offering it on site at the exchanges.

“My experience in the past 5 years of being faculty at the university and being a cofounder of a program like IDEA is that we really, if we’re going to be successful with engaging people who inject drugs in things like PrEP, we have to, like all things harm reduction, meet them where they’re at, both physically and mentally, and on their own terms,” said Dr. Tookes. “What better place than a syringe services program?”
 

Where people are: the exchanges

That’s where community health worker Farrington and others come in. More than 400 syringe access programs that exist in North America have PrEP programs, according to the North American Syringe Exchange Network (NASEN), and 86 of them report offering access to PrEP, either directly or through referrals. It’s an HIV prevention one-two punch: PrEP protects a person once they are exposed to HIV, and needle exchanges themselves reduce HIV transmission rates by reducing the odds that people will engage in behavior that exposes them to the virus in the first place.

So far, PrEP access for people who inject drugs looks different everywhere. At Las Vegas’ Huntridge Family Clinic, people can come to the lobby and pick up clean supplies from a syringe exchange vending machine, and while they’re there, talk to nurse practitioner Rob Phoenix, MSN, APRN, about HIV prevention.

In Cincinnati, where Adam Reilly, CDCA, runs a Ryan White–funded PrEP program out of the nonprofit Caracole, PrEP navigators go out with the syringe services vans run by the county health department and can connect them with providers willing to prescribe it. In Alabama, where needle exchanges are illegal, Farrington works as a community health worker through the North Alabama Area Health Education Center to go in to Huntsville’s legal tent cities to offer HIV and hepatitis C testing and tell them about PrEP. In Philadelphia, Drexel University, the city Department of Health, and Prevention Point Philadelphia co-offer PrEP through Prevention Point, which increased the number of people who inject drugs taking PrEP from just two to three a year to 584 times in 2021, according to Andres Freire, director of harm reduction health services at Prevention Point Philadelphia.

“Co-locating a PrEP clinic with our syringe-services program is the most effective means of delivering care to people who use drugs,” he said. “It is a friendly, nonstigmatizing place, as well as a place where individuals are already coming for services.”

At Dr. Tookes’ IDEA clinic and its PrEP study, people who inject drugs can not only get clean supplies, they can get a PrEP prescription on site and store their medications at the exchange so they don’t get stolen or used by others. And that idea didn’t come from him.

“It was one of my patients,” he said. “That person gave me an idea that impacted the health of hundreds of people in Miami.”

Indeed, Boston Health Care for the Homeless Program does the same. New data showed that what really worked for people who injected drugs in the group was not just medication storage on site but also PrEP prescriptions that lasted just a week at a time, or even same-day prescribing, as well as the program’s PrEP nurses showing up in person to their communities. That program managed to get PrEP referrals to 239 people, 152 of whom started taking PrEP. Six months later, 22 people were still using it.

But Dr. Tookes’s is a rare study on PrEP among people who inject drugs. The only data so far on the efficacy of PrEP for this group come from a 2013 study out of Thailand. Angela Bazzi, PhD, an associate professor of family medicine and public health at the University of California, San Diego, who studied the Boston program, said the dearth of research into effective ways of getting PrEP to people who inject drugs is fueling a negative feedback loop, where people who inject drugs and their providers largely don’t know about the HIV prevention pills, don’t see research on it, and therefore think it won’t work in people who inject drugs.

“There’s been a systematic exclusion of people who inject drugs from HIV prevention drug trials,” Dr. Bazzi told this news organization. Together with colleagues she wrote a viewpoint on the issue that was published in the International Journal of Drug Policy. “It really extends into effectiveness research, public health research, and clinical practice. We argued that the stigma surrounding addiction is the key driver of this.”

This is especially important, she said, because the U.S. Food and Drug Administration had been expected to make an approval decision on an injectable form of PrEP by Jan. 2021. That drug, cabotegravir, has been found to work for a month at a time. Injection drug users were excluded from the primary clinical trial of that drug, though a ViiV Healthcare spokesperson said the company is planning an after-market study in people who inject drugs some time in the future.
 

An incomplete solution

But syringe services aren’t enough, said Mr. Reilly. For one thing, public funding of PrEP programs can limit things like where navigators can send people. For instance, in Ohio, Mr. Reilly’s team can cover the costs of PrEP for people who inject drugs – but only with certain providers. State law prohibits them from contracting with Planned Parenthood.

Also, syringe services aren’t available everywhere. In Pennsylvania, where syringe services are legal only in the counties containing Philadelphia and Pittsburgh, the state’s two large cities, funding for basic syringe services precludes expanding services to offer PrEP.

“A lot of our focus has to stay with making sure our folks have access to the harm-reduction supplies they need, because the number of people we are seeing has grown exponentially during the pandemic,” said Katie Houston, a coordinator for Prevention Point Pittsburgh, which tries to address its clients’s PrEP needs by holding syringe-services distribution at a local clinic that provides PrEP. “Getting funding for our core supplies like syringes, crack pipes, and the works is extremely difficult because many grants/foundations don’t want to fund these supplies. And with the growing number of SSPs, the funding that has been available is being spread thin.”

And that means that traditional clinicians still have an important role to play, said Mr. Reilly.

“Syringe services programs are supposed to now provide treatment for hepatitis C and make sure people get on PrEP?” he said. “That seems like medical providers’s job.”

As for Farrington, operating as a solo health worker without the benefit of exchanges to help people like the young man who came to her house that night, she’ll keep going in to tent city and inviting sick people who inject drugs into her home to offer them what she can. She can’t legally offer syringe services. But she can keep checking in on people and offering them the help that’s available.

Recently, she saw that young man again. He was in a better place. He had found a place to live for the winter, so he wouldn’t have to stay in the hammock in someone’s yard when the temperatures dipped. And that was going a long way to stabilize everything else in his life. He’s still shooting up, she said, but having housing is making it easier for him to moderate his use. As for PrEP, he hasn’t started on that, either. But Farrington hasn’t given up hope.

“Not yet,” she said.

Dr. Tookes reports receiving research funding from Gilead Sciences. Dr. Calabrese reports receiving conference travel funding from Gilead Sciences. Farrington, Dr. Bazzi, Ms. Houston, Mr. Freire, and Mr. Reilly reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Not that long ago, a man in his mid-20s whom Morgan Farrington calls Kiddo showed up at her house with a fever, chills, and nausea. He was increasingly out of it. These were all signs of an abscess from missing a vein and using someone else’s syringe, said Farrington, founder of Goodworks, in Huntsville, Alabama.

But it wasn’t just an abscess. It was four blood clots and sepsis. He’d been craving his next fix of heroin so hard, and the relief that comes from the act of shooting up itself, that he’d dug a 3-day-old blood shot – a used syringe with someone else’s blood in it – out of the garbage and had used it.

“He was almost dead,” said Farrington. “Another day, maybe two, he would have been dead, for sure, for sure.”

Farrington gets it. She has her own history of injection drug use. She knows the compulsion to, in her words, “shoot up sugar water just to get a hit.” And that’s fine, she said. “I just wish that he would do so with his own safety in mind.”

So when he got out of the hospital a few weeks later, Farrington talked to him about not just clean syringes but also HIV pre-exposure prophylaxis (PrEP), the daily HIV prevention pills that have been found to be up to 84% protective against HIV in people who inject drugs. Both approaches – syringe services and PrEP – play a key role in the president’s new National HIV/AIDS Strategy. The strategy calls for expanding access to both services in traditional and nontraditional settings but doesn’t include mechanisms for that to happen.

Of the 1.2 million people in the U.S. who could benefit from PrEP, according to the Centers for Disease Control and Prevention, 23% are using it. But according to data published in 2020, just 0% and 5% of people who inject drugs who could benefit are using it. And most, like the guy Farrington continues to talk to, don’t even know it exists.
 

People who inject drugs are willing, clinicians may not be

Clinicians have a role to play, but right now, many clinicians act as gatekeepers, picking and choosing whom they’ll offer PrEP to. In 2014, just 1% of PrEP prescribers said they had prescribed the prevention pill to people who inject drugs. And recent data published in AIDS and Behavior showed that clinicians who expressed negative attitudes about people who injected drugs were less likely to offer to prescribe PrEP to a theoretical man who injected drugs asking for PrEP. There was a paradox in there, however: Clinicians were also more likely to think men who inject drugs were at high risk for acquiring HIV. But they also believed those men would be less likely to adhere, less safety conscious, and less responsible than gay and bisexual men. So, the investigators found that despite need, clinicians were more likely to prescribe to men at risk via sex than men at risk via injection drug use.

According to the CDC, to qualify for PrEP, the only requirements for people who inject drugs are testing negative for HIV and not sharing injection equipment – whether their injecting partners have confirmed HIV or whether their HIV status is unknown.

“As long as PrEP is a prescription, medication providers are really going to determine who accesses PrEP and who does not,” said study lead author Sarah Calabrese, PhD, assistant professor of psychiatry at George Washington University. “Even if you do anticipate that a patient might have adherence struggles. The solution is not withholding something that could be beneficial to them. The solution is supporting them to take that beneficial medication.”

And it appears that providers and regular people like Farrington have stepped into the access vacuum, with a decidedly harm-reduction approach: syringe services programs. While there’s no national data on how many people receive PrEP through needle exchange programs, those programs are the natural place to offer other health care services, said Hansel Tookes, MD, assistant professor of medicine at the University of Miami and founder of the Infectious Disease Elimination Act (IDEA) Syringe Exchange program and clinic. At the clinic, 80% of the people living with HIV have undetectable viral loads – a sign of good adherence to medication and general health. Previous research suggests that when people who inject drugs find out about PrEP, 57% are game for trying it. But early work suggests that people who inject drugs might need to access PrEP in a different way from other people who use PrEP.

Dr. Tookes is currently conducting a study looking at whether referring people who inject drugs out from needle exchanges to PrEP prescribers is as effective as offering it on site at the exchanges.

“My experience in the past 5 years of being faculty at the university and being a cofounder of a program like IDEA is that we really, if we’re going to be successful with engaging people who inject drugs in things like PrEP, we have to, like all things harm reduction, meet them where they’re at, both physically and mentally, and on their own terms,” said Dr. Tookes. “What better place than a syringe services program?”
 

Where people are: the exchanges

That’s where community health worker Farrington and others come in. More than 400 syringe access programs that exist in North America have PrEP programs, according to the North American Syringe Exchange Network (NASEN), and 86 of them report offering access to PrEP, either directly or through referrals. It’s an HIV prevention one-two punch: PrEP protects a person once they are exposed to HIV, and needle exchanges themselves reduce HIV transmission rates by reducing the odds that people will engage in behavior that exposes them to the virus in the first place.

So far, PrEP access for people who inject drugs looks different everywhere. At Las Vegas’ Huntridge Family Clinic, people can come to the lobby and pick up clean supplies from a syringe exchange vending machine, and while they’re there, talk to nurse practitioner Rob Phoenix, MSN, APRN, about HIV prevention.

In Cincinnati, where Adam Reilly, CDCA, runs a Ryan White–funded PrEP program out of the nonprofit Caracole, PrEP navigators go out with the syringe services vans run by the county health department and can connect them with providers willing to prescribe it. In Alabama, where needle exchanges are illegal, Farrington works as a community health worker through the North Alabama Area Health Education Center to go in to Huntsville’s legal tent cities to offer HIV and hepatitis C testing and tell them about PrEP. In Philadelphia, Drexel University, the city Department of Health, and Prevention Point Philadelphia co-offer PrEP through Prevention Point, which increased the number of people who inject drugs taking PrEP from just two to three a year to 584 times in 2021, according to Andres Freire, director of harm reduction health services at Prevention Point Philadelphia.

“Co-locating a PrEP clinic with our syringe-services program is the most effective means of delivering care to people who use drugs,” he said. “It is a friendly, nonstigmatizing place, as well as a place where individuals are already coming for services.”

At Dr. Tookes’ IDEA clinic and its PrEP study, people who inject drugs can not only get clean supplies, they can get a PrEP prescription on site and store their medications at the exchange so they don’t get stolen or used by others. And that idea didn’t come from him.

“It was one of my patients,” he said. “That person gave me an idea that impacted the health of hundreds of people in Miami.”

Indeed, Boston Health Care for the Homeless Program does the same. New data showed that what really worked for people who injected drugs in the group was not just medication storage on site but also PrEP prescriptions that lasted just a week at a time, or even same-day prescribing, as well as the program’s PrEP nurses showing up in person to their communities. That program managed to get PrEP referrals to 239 people, 152 of whom started taking PrEP. Six months later, 22 people were still using it.

But Dr. Tookes’s is a rare study on PrEP among people who inject drugs. The only data so far on the efficacy of PrEP for this group come from a 2013 study out of Thailand. Angela Bazzi, PhD, an associate professor of family medicine and public health at the University of California, San Diego, who studied the Boston program, said the dearth of research into effective ways of getting PrEP to people who inject drugs is fueling a negative feedback loop, where people who inject drugs and their providers largely don’t know about the HIV prevention pills, don’t see research on it, and therefore think it won’t work in people who inject drugs.

“There’s been a systematic exclusion of people who inject drugs from HIV prevention drug trials,” Dr. Bazzi told this news organization. Together with colleagues she wrote a viewpoint on the issue that was published in the International Journal of Drug Policy. “It really extends into effectiveness research, public health research, and clinical practice. We argued that the stigma surrounding addiction is the key driver of this.”

This is especially important, she said, because the U.S. Food and Drug Administration had been expected to make an approval decision on an injectable form of PrEP by Jan. 2021. That drug, cabotegravir, has been found to work for a month at a time. Injection drug users were excluded from the primary clinical trial of that drug, though a ViiV Healthcare spokesperson said the company is planning an after-market study in people who inject drugs some time in the future.
 

An incomplete solution

But syringe services aren’t enough, said Mr. Reilly. For one thing, public funding of PrEP programs can limit things like where navigators can send people. For instance, in Ohio, Mr. Reilly’s team can cover the costs of PrEP for people who inject drugs – but only with certain providers. State law prohibits them from contracting with Planned Parenthood.

Also, syringe services aren’t available everywhere. In Pennsylvania, where syringe services are legal only in the counties containing Philadelphia and Pittsburgh, the state’s two large cities, funding for basic syringe services precludes expanding services to offer PrEP.

“A lot of our focus has to stay with making sure our folks have access to the harm-reduction supplies they need, because the number of people we are seeing has grown exponentially during the pandemic,” said Katie Houston, a coordinator for Prevention Point Pittsburgh, which tries to address its clients’s PrEP needs by holding syringe-services distribution at a local clinic that provides PrEP. “Getting funding for our core supplies like syringes, crack pipes, and the works is extremely difficult because many grants/foundations don’t want to fund these supplies. And with the growing number of SSPs, the funding that has been available is being spread thin.”

And that means that traditional clinicians still have an important role to play, said Mr. Reilly.

“Syringe services programs are supposed to now provide treatment for hepatitis C and make sure people get on PrEP?” he said. “That seems like medical providers’s job.”

As for Farrington, operating as a solo health worker without the benefit of exchanges to help people like the young man who came to her house that night, she’ll keep going in to tent city and inviting sick people who inject drugs into her home to offer them what she can. She can’t legally offer syringe services. But she can keep checking in on people and offering them the help that’s available.

Recently, she saw that young man again. He was in a better place. He had found a place to live for the winter, so he wouldn’t have to stay in the hammock in someone’s yard when the temperatures dipped. And that was going a long way to stabilize everything else in his life. He’s still shooting up, she said, but having housing is making it easier for him to moderate his use. As for PrEP, he hasn’t started on that, either. But Farrington hasn’t given up hope.

“Not yet,” she said.

Dr. Tookes reports receiving research funding from Gilead Sciences. Dr. Calabrese reports receiving conference travel funding from Gilead Sciences. Farrington, Dr. Bazzi, Ms. Houston, Mr. Freire, and Mr. Reilly reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Can geospatial mapping fill in the gaps in areas lagging behind in global efforts to end the HIV epidemic?

That’s what Diego Cuadros, PhD, assistant professor of health geography and disease modeling at the University of Cincinnati, set out to learn using geospatial data combined with prevalence data to identify the most underserved areas in Sub-Saharan Africa (SSA) for HIV services.

Study findings, which were published Nov. 24 in PLOS Global Public Health, highlight that as many as 1.5 million people living with HIV (PLHIV) in SSA have more than an hour’s motorized travel time both ways to access care, while roughly 3 million must set aside, at minimum, 30 minutes. When the only mode of transportation is walking, as much as 95.3% of underserved areas are faced with at least 30 minutes travel time.

This is simply the tip of the overall problem, Dr. Cuadros told this news organization.

“We are able to estimate how many people [whose] quality of life is being affected by HIV because they are not on treatment and most probably, HIV incidence is high in those areas. But [it’s not as simple as just] increasing the number of health care facilities,” he said. “We need to find strategies to be able to cover this population.”

Dr. Cuadros also noted that the problem goes both ways. “It’s hard for them to move, and it’s [also] hard to reach them,” he explained.
 

Mapping care, or lack thereof

Dr. Cuadros and team used two primary sources of data to generate high-resolution maps of underserved SSA areas: estimated number of PLHIV between the ages of 15 and 49 years in 47 SSA countries paired with population density and global map of travel time to the nearest health facility by motorized and nonmotorized (that is, walking) transportation. Combining these data allowed them to then detail the distance from access to care for every 5 km².

The mapping exercise showed that 90.5% of the total territory, in which about 7 million PLHIV resided, had more than 10 minutes motorized travel time to the nearest health care facility, while 74.6% were within 30 minutes, and 58.9% were within 60 minutes. Increases in threshold travel times (from 10 to 60 minutes) corresponded directly to declines in the average proportion of underserved areas (from 80.9% to 42.6%). However, in certain countries like Sudan and Mauritania, 99.4% of the areas were underserved at the 10 minute threshold, while more than 90% were underserved at the 60 minute threshold.

Corresponding rates for nonmotorized access to health services were similar: 88.7% (~17.6 million) PLHIV had 10 minutes walking time to health care services, while 57.8% (~11.5 million) had at least 30 minutes, and 33.0% (~6.6 million), at least 60 minutes. Likewise, as threshold times increased from 10 to 60 minutes, the percentage of affected PLHIV declined (to roughly 50% in two-thirds of the countries). But more than 70% of PLHIV resided in underserved areas in countries like Equatorial Guinea, Eritrea, South Sudan, and Sudan.
 

Geographical allocation of health service facilities underscores treatment gaps

“We think that most PLHIV live in urban areas or close to urban areas, and most of the health care facilities in Africa are concentrated in those areas. But [roughly 8 million people with HIV] are living in rural areas, and for most, movement is very difficult,” explained Dr. Cuadros, meaning that the majority are not on treatment despite the high incidence of HIV.

Inarguably, the pandemic has interrupted HIV services and treatment substantially on the African continent, further challenging any efforts to translate these study findings into actionable strategies.

“We’ve known for quite a while that distance and travel times and travel expenses are known risks for nonadherence, for lack of access to diagnostics, for people at risk for exposure,” Chris Beyrer, MD, MPH, Desmond M. Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, Baltimore, said in an interview. (Dr. Beyrer was not involved in the study.)

“What’s new is the ability to really look at this across geographies and really home in on how many people face very long times and distances for travel. That’s a really important contribution,” he said.

Dr. Cuadros pointed out that these hard-to-reach populations are key to achieving the UNAID’s HIV elimination targets. “We’re going to have these pockets of transmission that are going to be really important for epidemic control,” he explained.

Toward that end, the onus appears to extend well beyond solutions that emphasize difficulty in reaching people from the provider perspective. “There’s quite a lot of what you might want to think of as blaming the victim for when people miss appointments, don’t appear to be adherent, [or] can’t stay reliably suppressed,” said Dr. Beyrer.

“It’s really important for providers in general to include in history and intake how far people have come, what their challenges are with travel, to really pay attention to those issues. Having this elegant analysis, this level of detail, is an important first step,” he added.

Dr. Cuadros has disclosed no relevant financial relationships. Dr. Beyrer reports a consulting agreement with Merck.

A version of this article first appeared on Medscape.com.

Can geospatial mapping fill in the gaps in areas lagging behind in global efforts to end the HIV epidemic?

That’s what Diego Cuadros, PhD, assistant professor of health geography and disease modeling at the University of Cincinnati, set out to learn using geospatial data combined with prevalence data to identify the most underserved areas in Sub-Saharan Africa (SSA) for HIV services.

Study findings, which were published Nov. 24 in PLOS Global Public Health, highlight that as many as 1.5 million people living with HIV (PLHIV) in SSA have more than an hour’s motorized travel time both ways to access care, while roughly 3 million must set aside, at minimum, 30 minutes. When the only mode of transportation is walking, as much as 95.3% of underserved areas are faced with at least 30 minutes travel time.

This is simply the tip of the overall problem, Dr. Cuadros told this news organization.

“We are able to estimate how many people [whose] quality of life is being affected by HIV because they are not on treatment and most probably, HIV incidence is high in those areas. But [it’s not as simple as just] increasing the number of health care facilities,” he said. “We need to find strategies to be able to cover this population.”

Dr. Cuadros also noted that the problem goes both ways. “It’s hard for them to move, and it’s [also] hard to reach them,” he explained.
 

Mapping care, or lack thereof

Dr. Cuadros and team used two primary sources of data to generate high-resolution maps of underserved SSA areas: estimated number of PLHIV between the ages of 15 and 49 years in 47 SSA countries paired with population density and global map of travel time to the nearest health facility by motorized and nonmotorized (that is, walking) transportation. Combining these data allowed them to then detail the distance from access to care for every 5 km².

The mapping exercise showed that 90.5% of the total territory, in which about 7 million PLHIV resided, had more than 10 minutes motorized travel time to the nearest health care facility, while 74.6% were within 30 minutes, and 58.9% were within 60 minutes. Increases in threshold travel times (from 10 to 60 minutes) corresponded directly to declines in the average proportion of underserved areas (from 80.9% to 42.6%). However, in certain countries like Sudan and Mauritania, 99.4% of the areas were underserved at the 10 minute threshold, while more than 90% were underserved at the 60 minute threshold.

Corresponding rates for nonmotorized access to health services were similar: 88.7% (~17.6 million) PLHIV had 10 minutes walking time to health care services, while 57.8% (~11.5 million) had at least 30 minutes, and 33.0% (~6.6 million), at least 60 minutes. Likewise, as threshold times increased from 10 to 60 minutes, the percentage of affected PLHIV declined (to roughly 50% in two-thirds of the countries). But more than 70% of PLHIV resided in underserved areas in countries like Equatorial Guinea, Eritrea, South Sudan, and Sudan.
 

Geographical allocation of health service facilities underscores treatment gaps

“We think that most PLHIV live in urban areas or close to urban areas, and most of the health care facilities in Africa are concentrated in those areas. But [roughly 8 million people with HIV] are living in rural areas, and for most, movement is very difficult,” explained Dr. Cuadros, meaning that the majority are not on treatment despite the high incidence of HIV.

Inarguably, the pandemic has interrupted HIV services and treatment substantially on the African continent, further challenging any efforts to translate these study findings into actionable strategies.

“We’ve known for quite a while that distance and travel times and travel expenses are known risks for nonadherence, for lack of access to diagnostics, for people at risk for exposure,” Chris Beyrer, MD, MPH, Desmond M. Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, Baltimore, said in an interview. (Dr. Beyrer was not involved in the study.)

“What’s new is the ability to really look at this across geographies and really home in on how many people face very long times and distances for travel. That’s a really important contribution,” he said.

Dr. Cuadros pointed out that these hard-to-reach populations are key to achieving the UNAID’s HIV elimination targets. “We’re going to have these pockets of transmission that are going to be really important for epidemic control,” he explained.

Toward that end, the onus appears to extend well beyond solutions that emphasize difficulty in reaching people from the provider perspective. “There’s quite a lot of what you might want to think of as blaming the victim for when people miss appointments, don’t appear to be adherent, [or] can’t stay reliably suppressed,” said Dr. Beyrer.

“It’s really important for providers in general to include in history and intake how far people have come, what their challenges are with travel, to really pay attention to those issues. Having this elegant analysis, this level of detail, is an important first step,” he added.

Dr. Cuadros has disclosed no relevant financial relationships. Dr. Beyrer reports a consulting agreement with Merck.

A version of this article first appeared on Medscape.com.

Can geospatial mapping fill in the gaps in areas lagging behind in global efforts to end the HIV epidemic?

That’s what Diego Cuadros, PhD, assistant professor of health geography and disease modeling at the University of Cincinnati, set out to learn using geospatial data combined with prevalence data to identify the most underserved areas in Sub-Saharan Africa (SSA) for HIV services.

Study findings, which were published Nov. 24 in PLOS Global Public Health, highlight that as many as 1.5 million people living with HIV (PLHIV) in SSA have more than an hour’s motorized travel time both ways to access care, while roughly 3 million must set aside, at minimum, 30 minutes. When the only mode of transportation is walking, as much as 95.3% of underserved areas are faced with at least 30 minutes travel time.

This is simply the tip of the overall problem, Dr. Cuadros told this news organization.

“We are able to estimate how many people [whose] quality of life is being affected by HIV because they are not on treatment and most probably, HIV incidence is high in those areas. But [it’s not as simple as just] increasing the number of health care facilities,” he said. “We need to find strategies to be able to cover this population.”

Dr. Cuadros also noted that the problem goes both ways. “It’s hard for them to move, and it’s [also] hard to reach them,” he explained.
 

Mapping care, or lack thereof

Dr. Cuadros and team used two primary sources of data to generate high-resolution maps of underserved SSA areas: estimated number of PLHIV between the ages of 15 and 49 years in 47 SSA countries paired with population density and global map of travel time to the nearest health facility by motorized and nonmotorized (that is, walking) transportation. Combining these data allowed them to then detail the distance from access to care for every 5 km².

The mapping exercise showed that 90.5% of the total territory, in which about 7 million PLHIV resided, had more than 10 minutes motorized travel time to the nearest health care facility, while 74.6% were within 30 minutes, and 58.9% were within 60 minutes. Increases in threshold travel times (from 10 to 60 minutes) corresponded directly to declines in the average proportion of underserved areas (from 80.9% to 42.6%). However, in certain countries like Sudan and Mauritania, 99.4% of the areas were underserved at the 10 minute threshold, while more than 90% were underserved at the 60 minute threshold.

Corresponding rates for nonmotorized access to health services were similar: 88.7% (~17.6 million) PLHIV had 10 minutes walking time to health care services, while 57.8% (~11.5 million) had at least 30 minutes, and 33.0% (~6.6 million), at least 60 minutes. Likewise, as threshold times increased from 10 to 60 minutes, the percentage of affected PLHIV declined (to roughly 50% in two-thirds of the countries). But more than 70% of PLHIV resided in underserved areas in countries like Equatorial Guinea, Eritrea, South Sudan, and Sudan.
 

Geographical allocation of health service facilities underscores treatment gaps

“We think that most PLHIV live in urban areas or close to urban areas, and most of the health care facilities in Africa are concentrated in those areas. But [roughly 8 million people with HIV] are living in rural areas, and for most, movement is very difficult,” explained Dr. Cuadros, meaning that the majority are not on treatment despite the high incidence of HIV.

Inarguably, the pandemic has interrupted HIV services and treatment substantially on the African continent, further challenging any efforts to translate these study findings into actionable strategies.

“We’ve known for quite a while that distance and travel times and travel expenses are known risks for nonadherence, for lack of access to diagnostics, for people at risk for exposure,” Chris Beyrer, MD, MPH, Desmond M. Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, Baltimore, said in an interview. (Dr. Beyrer was not involved in the study.)

“What’s new is the ability to really look at this across geographies and really home in on how many people face very long times and distances for travel. That’s a really important contribution,” he said.

Dr. Cuadros pointed out that these hard-to-reach populations are key to achieving the UNAID’s HIV elimination targets. “We’re going to have these pockets of transmission that are going to be really important for epidemic control,” he explained.

Toward that end, the onus appears to extend well beyond solutions that emphasize difficulty in reaching people from the provider perspective. “There’s quite a lot of what you might want to think of as blaming the victim for when people miss appointments, don’t appear to be adherent, [or] can’t stay reliably suppressed,” said Dr. Beyrer.

“It’s really important for providers in general to include in history and intake how far people have come, what their challenges are with travel, to really pay attention to those issues. Having this elegant analysis, this level of detail, is an important first step,” he added.

Dr. Cuadros has disclosed no relevant financial relationships. Dr. Beyrer reports a consulting agreement with Merck.

A version of this article first appeared on Medscape.com.

Over the past 2 years, the COVID-19 pandemic has caused numerous disruptions in health care, including in global HIV/AIDS services. But new data presented at the Association of Nurses in AIDS Care (ANAC) 2021 Annual Meeting suggest that practitioners quickly adapted to challenges posed by the pandemic, and care and prevention services around the world have begun to return to prepandemic levels.

These rebounding numbers “show how resilient the HIV system can be,” Jennifer Kates, PhD, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation (KFF), said in an interview. She presented the data during her ANAC plenary talk on Nov. 11. Dr. Kates noted that continued recovery relies on improving global access to and delivery of COVID-19 vaccines. “If we do not have control of COVID, we are going to see endless cycles of impact,” she said during her talk.
 

COVID-19 and HIV services

Although there was concern that the pandemic could disrupt access to antiretrovirals, the Global Fund previously reported a nearly 9% increase in people receiving antiretroviral therapy (ART) from 2019 to 2020. HIV prevention and testing did take a hit: There was a 22% decrease in testing for HIV and an 11% decline in the number of people receiving HIV prevention services over that period.

New data from the President’s Emergency Plan for AIDS Relief (PEPFAR) showed similar trends. Consistent with the Global Fund’s findings, a KFF analysis of PEPFAR data found that the number of people receiving ART grew in 2020, climbing from 16.0 million in the first quarter (Q1) of 2020 to 17.4 million by the end of the year. The most recent data from PEPFAR suggest that the number had climbed to 18.4 million by September 2021.

However, there was a 24% decrease in the number of newly enrolled individuals receiving ART from Q2 to Q3 in 2020. It dipped from 669,436 to 509,509. There was a similar decrease in the number of people being tested for HIV, dropping 25% from an estimated 16,700 to 12,500 from Q2 to Q3. But by the end of the year, both measurements had rebounded: New enrollments in ART grew 31%, and HIV testing grew nearly 41% compared to Q3.

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program, which is focused on adolescent girls and young women, saw a dip in preexposure prophylaxis (PrEP) and other preventive services in Q4 2020, but numbers surpassed prepandemic levels by June 2021.

PEPFAR helped speed recovery, Dr. Kates said, by providing guidance on COVID-19 protocols to the field and implementing innovations, such as accelerated 3- and 6-month medication dispensing, virtual platforms, and decentralized drug delivery. In addition, the U.S. Congress allocated $3.8 billion in emergency funding in fiscal year 2021 to help mitigate the effects of COVID-19 on HIV and AIDS care.
 

Longer-term outcomes still unclear

Although these numbers are encouraging, some of the effects of COVID-19 on the HIV epidemic are still unknown – in particular, whether these documented dips in preventive services will translate to an increase in new infections. This will not be clear until a year or 2 from now, Dr. Kates noted. Increased use of ART as well as an increase in some behaviors associated with the pandemic, such as decreased social contact, are factors that mitigate an increase in the rate of infections, she said, but “how that all is going to play out we don’t know for sure.”

Other conference attendees expressed anxiety about the possibility of an increase in the rate of infections. “I’m waiting for the other shoe to drop, as it were,” Barb Cardell, training and technical assistance director at Positive Women’s Network–USA, in Oakland, Calif., said in an interview. The Positive Women’s Network is a national organization of women living with HIV. “Starting late in 2019, we have been cautioning public health officials in states and federally that there will likely be an uptick in HIV diagnosis as we return to whatever ‘normal’ looks like these days,” Ms. Cardell noted, adding, “We have all heard stories of folks that had an exposure and weren’t able to access PrEP during the pandemic and hence seroconverted.”

Kara McGee, associate clinical professor at Duke University School of Nursing, Durham, N.C., shared similar sentiments. “Many people at risk of acquiring HIV had trouble accessing testing and prevention prior to the pandemic, and service interruptions due to the COVID-19 pandemic have only worsened access – especially in rural areas,” she told this news organization.

Need for equitable vaccine access

For HIV services to continue to rebound, COVID-19 vaccination needs to be made a priority globally, Dr. Kates said. But data suggest lower-income countries are being left behind. In high-income countries, 65% of the population has been fully vaccinated, compared to 2% of people in the lowest-income countries. A KFF analysis projected that at the current rates of vaccination, these disparities will widen over time. COVID-19 testing rates in lower-income countries also lag. In high-income countries, 740 tests per 100,000 individuals are conducted daily; in low-income countries, that rate is 13 daily tests per 100,000 people. Until we can achieve more equitable access globally, the documented recovery of HIV is “precarious,” Dr. Kates said.

Ms. McGee agreed with Dr. Kates and was surprised by the extent of global inequities in the COVID-19 response. She said these issues should be a focus for the HIV health care community moving forward. “I think there are lot of us who have worked in the HIV field for many years – both domestically and internationally – who did not fully grasp the global disparities and need to consider how we can advocate for more equal access and distribution,” she said.

A version of this article first appeared on Medscape.com.

Over the past 2 years, the COVID-19 pandemic has caused numerous disruptions in health care, including in global HIV/AIDS services. But new data presented at the Association of Nurses in AIDS Care (ANAC) 2021 Annual Meeting suggest that practitioners quickly adapted to challenges posed by the pandemic, and care and prevention services around the world have begun to return to prepandemic levels.

These rebounding numbers “show how resilient the HIV system can be,” Jennifer Kates, PhD, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation (KFF), said in an interview. She presented the data during her ANAC plenary talk on Nov. 11. Dr. Kates noted that continued recovery relies on improving global access to and delivery of COVID-19 vaccines. “If we do not have control of COVID, we are going to see endless cycles of impact,” she said during her talk.
 

COVID-19 and HIV services

Although there was concern that the pandemic could disrupt access to antiretrovirals, the Global Fund previously reported a nearly 9% increase in people receiving antiretroviral therapy (ART) from 2019 to 2020. HIV prevention and testing did take a hit: There was a 22% decrease in testing for HIV and an 11% decline in the number of people receiving HIV prevention services over that period.

New data from the President’s Emergency Plan for AIDS Relief (PEPFAR) showed similar trends. Consistent with the Global Fund’s findings, a KFF analysis of PEPFAR data found that the number of people receiving ART grew in 2020, climbing from 16.0 million in the first quarter (Q1) of 2020 to 17.4 million by the end of the year. The most recent data from PEPFAR suggest that the number had climbed to 18.4 million by September 2021.

However, there was a 24% decrease in the number of newly enrolled individuals receiving ART from Q2 to Q3 in 2020. It dipped from 669,436 to 509,509. There was a similar decrease in the number of people being tested for HIV, dropping 25% from an estimated 16,700 to 12,500 from Q2 to Q3. But by the end of the year, both measurements had rebounded: New enrollments in ART grew 31%, and HIV testing grew nearly 41% compared to Q3.

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program, which is focused on adolescent girls and young women, saw a dip in preexposure prophylaxis (PrEP) and other preventive services in Q4 2020, but numbers surpassed prepandemic levels by June 2021.

PEPFAR helped speed recovery, Dr. Kates said, by providing guidance on COVID-19 protocols to the field and implementing innovations, such as accelerated 3- and 6-month medication dispensing, virtual platforms, and decentralized drug delivery. In addition, the U.S. Congress allocated $3.8 billion in emergency funding in fiscal year 2021 to help mitigate the effects of COVID-19 on HIV and AIDS care.
 

Longer-term outcomes still unclear

Although these numbers are encouraging, some of the effects of COVID-19 on the HIV epidemic are still unknown – in particular, whether these documented dips in preventive services will translate to an increase in new infections. This will not be clear until a year or 2 from now, Dr. Kates noted. Increased use of ART as well as an increase in some behaviors associated with the pandemic, such as decreased social contact, are factors that mitigate an increase in the rate of infections, she said, but “how that all is going to play out we don’t know for sure.”

Other conference attendees expressed anxiety about the possibility of an increase in the rate of infections. “I’m waiting for the other shoe to drop, as it were,” Barb Cardell, training and technical assistance director at Positive Women’s Network–USA, in Oakland, Calif., said in an interview. The Positive Women’s Network is a national organization of women living with HIV. “Starting late in 2019, we have been cautioning public health officials in states and federally that there will likely be an uptick in HIV diagnosis as we return to whatever ‘normal’ looks like these days,” Ms. Cardell noted, adding, “We have all heard stories of folks that had an exposure and weren’t able to access PrEP during the pandemic and hence seroconverted.”

Kara McGee, associate clinical professor at Duke University School of Nursing, Durham, N.C., shared similar sentiments. “Many people at risk of acquiring HIV had trouble accessing testing and prevention prior to the pandemic, and service interruptions due to the COVID-19 pandemic have only worsened access – especially in rural areas,” she told this news organization.

Need for equitable vaccine access

For HIV services to continue to rebound, COVID-19 vaccination needs to be made a priority globally, Dr. Kates said. But data suggest lower-income countries are being left behind. In high-income countries, 65% of the population has been fully vaccinated, compared to 2% of people in the lowest-income countries. A KFF analysis projected that at the current rates of vaccination, these disparities will widen over time. COVID-19 testing rates in lower-income countries also lag. In high-income countries, 740 tests per 100,000 individuals are conducted daily; in low-income countries, that rate is 13 daily tests per 100,000 people. Until we can achieve more equitable access globally, the documented recovery of HIV is “precarious,” Dr. Kates said.

Ms. McGee agreed with Dr. Kates and was surprised by the extent of global inequities in the COVID-19 response. She said these issues should be a focus for the HIV health care community moving forward. “I think there are lot of us who have worked in the HIV field for many years – both domestically and internationally – who did not fully grasp the global disparities and need to consider how we can advocate for more equal access and distribution,” she said.

A version of this article first appeared on Medscape.com.

Over the past 2 years, the COVID-19 pandemic has caused numerous disruptions in health care, including in global HIV/AIDS services. But new data presented at the Association of Nurses in AIDS Care (ANAC) 2021 Annual Meeting suggest that practitioners quickly adapted to challenges posed by the pandemic, and care and prevention services around the world have begun to return to prepandemic levels.

These rebounding numbers “show how resilient the HIV system can be,” Jennifer Kates, PhD, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation (KFF), said in an interview. She presented the data during her ANAC plenary talk on Nov. 11. Dr. Kates noted that continued recovery relies on improving global access to and delivery of COVID-19 vaccines. “If we do not have control of COVID, we are going to see endless cycles of impact,” she said during her talk.
 

COVID-19 and HIV services

Although there was concern that the pandemic could disrupt access to antiretrovirals, the Global Fund previously reported a nearly 9% increase in people receiving antiretroviral therapy (ART) from 2019 to 2020. HIV prevention and testing did take a hit: There was a 22% decrease in testing for HIV and an 11% decline in the number of people receiving HIV prevention services over that period.

New data from the President’s Emergency Plan for AIDS Relief (PEPFAR) showed similar trends. Consistent with the Global Fund’s findings, a KFF analysis of PEPFAR data found that the number of people receiving ART grew in 2020, climbing from 16.0 million in the first quarter (Q1) of 2020 to 17.4 million by the end of the year. The most recent data from PEPFAR suggest that the number had climbed to 18.4 million by September 2021.

However, there was a 24% decrease in the number of newly enrolled individuals receiving ART from Q2 to Q3 in 2020. It dipped from 669,436 to 509,509. There was a similar decrease in the number of people being tested for HIV, dropping 25% from an estimated 16,700 to 12,500 from Q2 to Q3. But by the end of the year, both measurements had rebounded: New enrollments in ART grew 31%, and HIV testing grew nearly 41% compared to Q3.

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program, which is focused on adolescent girls and young women, saw a dip in preexposure prophylaxis (PrEP) and other preventive services in Q4 2020, but numbers surpassed prepandemic levels by June 2021.

PEPFAR helped speed recovery, Dr. Kates said, by providing guidance on COVID-19 protocols to the field and implementing innovations, such as accelerated 3- and 6-month medication dispensing, virtual platforms, and decentralized drug delivery. In addition, the U.S. Congress allocated $3.8 billion in emergency funding in fiscal year 2021 to help mitigate the effects of COVID-19 on HIV and AIDS care.
 

Longer-term outcomes still unclear

Although these numbers are encouraging, some of the effects of COVID-19 on the HIV epidemic are still unknown – in particular, whether these documented dips in preventive services will translate to an increase in new infections. This will not be clear until a year or 2 from now, Dr. Kates noted. Increased use of ART as well as an increase in some behaviors associated with the pandemic, such as decreased social contact, are factors that mitigate an increase in the rate of infections, she said, but “how that all is going to play out we don’t know for sure.”

Other conference attendees expressed anxiety about the possibility of an increase in the rate of infections. “I’m waiting for the other shoe to drop, as it were,” Barb Cardell, training and technical assistance director at Positive Women’s Network–USA, in Oakland, Calif., said in an interview. The Positive Women’s Network is a national organization of women living with HIV. “Starting late in 2019, we have been cautioning public health officials in states and federally that there will likely be an uptick in HIV diagnosis as we return to whatever ‘normal’ looks like these days,” Ms. Cardell noted, adding, “We have all heard stories of folks that had an exposure and weren’t able to access PrEP during the pandemic and hence seroconverted.”

Kara McGee, associate clinical professor at Duke University School of Nursing, Durham, N.C., shared similar sentiments. “Many people at risk of acquiring HIV had trouble accessing testing and prevention prior to the pandemic, and service interruptions due to the COVID-19 pandemic have only worsened access – especially in rural areas,” she told this news organization.

Need for equitable vaccine access

For HIV services to continue to rebound, COVID-19 vaccination needs to be made a priority globally, Dr. Kates said. But data suggest lower-income countries are being left behind. In high-income countries, 65% of the population has been fully vaccinated, compared to 2% of people in the lowest-income countries. A KFF analysis projected that at the current rates of vaccination, these disparities will widen over time. COVID-19 testing rates in lower-income countries also lag. In high-income countries, 740 tests per 100,000 individuals are conducted daily; in low-income countries, that rate is 13 daily tests per 100,000 people. Until we can achieve more equitable access globally, the documented recovery of HIV is “precarious,” Dr. Kates said.

Ms. McGee agreed with Dr. Kates and was surprised by the extent of global inequities in the COVID-19 response. She said these issues should be a focus for the HIV health care community moving forward. “I think there are lot of us who have worked in the HIV field for many years – both domestically and internationally – who did not fully grasp the global disparities and need to consider how we can advocate for more equal access and distribution,” she said.

A version of this article first appeared on Medscape.com.

It sounds like a fairy tale steeped in HIV stigma: A woman wakes up one morning and, poof, the HIV she’s been living with for 8 years is gone. But for a 30-year-old Argentinian woman from the aptly named village of Esperanza, that’s close to the truth, according to an article published in Annals of Internal Medicine.

The woman, the so-called Esperanza Patient, appears to be the second person whose immune system cleared the virus without the use of stem cell transplantation. The first was Loreen Willenberg, a California woman who, after living with HIV for 27 years, no longer had replicating HIV in her system. That case was reported last year.

“That’s the beauty of this name, right? Esperanza,” said Xu Yu, MD, principal investigator of the Ragon Institute of Massachusetts General Hospital, the Massachusetts Institute of Technology, and Harvard University, Boston, referring to the Spanish word for “hope.” “This makes us hopeful that a natural cure of HIV is actually possible.”

Two other people appear to have cleared HIV, but only after full replacement of the immune system via stem cell transplantation – the Berlin Patient, Timothy Ray Brown, and the London Patient. Another man, from Brazil, appeared to have an undetectable viral load after receiving intensified antiretroviral treatment plus supplemental vitamin B3.
 

The rarest of the rare

The Esperanza Patient is among a rare group of people living with HIV called elite controllers. These people’s immune systems can control HIV without antiretrovirals. Most elite controllers’ immune systems, however, can’t mount the immune attack necessary to eliminate all replicating HIV from their systems. Instead, their immune systems control the virus without affecting the reservoirs where HIV continues to make copies of itself and can spread.

The Esperanza Patient and Ms. Willenberg, however, appear to be the rarest of the rare. Their own immune systems seem not only to have stopped HIV replication outside of reservoirs but also to have stormed those reservoirs and killed all virus that might have continued to replicate.

The two women are connected in another way: At an HIV conference in 2019, Dr. Yu was presenting data on Ms. Willenberg’s case. At that conference, she met Natalia Laufer, MD, PhD, associate researcher at the Instituto de Investigaciones Biomédicas en Retrovirs y SIDA at the University of Buenos Aires. Dr. Laufer had been studying the Esperanza Patient at the time and asked Dr. Yu whether she and her team at the Ragon Institute could help her sequence the patient’s HIV genome to see whether, indeed, the virus had been spontaneously cleared from the patient’s system.

So that’s what the pair did, in collaboration with several other researchers into cures for HIV. The Esperanza Patient first acquired HIV in 2013, but in the 8 years that followed, results of 10 conventional viral load tests indicated the virus was undetectable (that is, below the level of quantification for standard technology). During that time, the woman’s boyfriend, from whom she had acquired HIV, died of AIDS-defining illnesses. She subsequently married and had a baby. Both her partner and baby are HIV negative. She only received HIV treatment for 6 months while she was pregnant.
 

A fossil record of HIV

Yet, there was still HIV in the woman’s system. Dr. Laufer and Dr. Yu wanted to know whether that HIV was transmissible or whether it was a relic from when HIV was still replicating and was now defective and incapable of replicating. They performed extensive genome sequencing on nearly 1.2 billion cells that Dr. Laufer had taken from the patient’s blood in 2017, 2018, 2019, and 2020, an additional 503 million cells that were from the placenta of the baby she gave birth to in 2020, and 150 million resting CD4 T cells. Proviral sequencing was undertaken of the full DNA of the HIV to detect whether the virus was still intact. The DNA was then analyzed by use of an algorithm and was tested for mutations. The investigators tested the patient’s CD4 cells to determine whether the cells still harbored any latent HIV.

In this way, they conducted a full viral workup using tests that are far more sensitive than the viral load tests the woman had undergone in the clinic. The investigators then assessed the patient’s immune system to see what the various cells of the immune system could tell them about how well her natural immune system could identify and kill HIV. They isolated the Esperanza Patient’s immune cells and subjected those cells to HIV in the lab to see whether the cells could detect and eliminate the virus.

And just to be safe, they checked to make sure there were no antiretroviral drugs in the patient’s system.

What they found was that without treatment, her CD4 count hovered around 1,000 cells – a sign of a functioning immune system. DNA sequences revealed large chunks of missing DNA, and one sequence had an immune-induced hypermutation. In total, seven proviruses were found, but none were capable of replicating. The CD4 cells they evaluated showed no evidence of latent HIV.

In other words, they had uncovered a fossil record.

“These HIV-1 DNA products clearly indicate that this person was infected with HIV-1 in the past and that active cycles of viral replication had occurred at one point,” Dr. Yu and colleagues write in their recent article.

What may be more useful to researchers looking to turn this spontaneous cure into treatment for millions of people living with active HIV was the evidence that the woman’s immune system had trained itself to attack HIV through a number of genetic mutations. What they found, the researchers write, was evidence of “an incomplete seroconversion” – that is, when the patient was acquiring HIV, the infection was stopped in its tracks.

Yet, Dr. Yu and colleagues say that they can’t prove that the woman is fully cured of HIV.

“Although this might sound unsatisfying, it reflects an intrinsic limitation of scientific research,” they write. “Scientific concepts can never be proved through empirical data collection; they can only be disproved.”
 

There are more out there

Are these women the only ones to have spontaneously cleared HIV? That’s the question, said Carl Dieffenbach, PhD, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. Just like they can’t disprove that the women cured themselves, they can’t prove that she and Ms. Willenberg are the only two people to have experienced this cure.

“We’re all struggling with this,” Dr. Dieffenbach told this news organization. “The goal is to get enough of these people so maybe there’s a road map to how to induce, trigger, change immunity. But this could well be a unique event at the time of initiation of infection. We just don’t know.”

What is needed, Dr. Yu said, is for clinicians to reach out to them regarding cases that could mimic the cases of Ms. Willenberg and the Esperanza Patient. Elaborate testing could then be conducted to see whether these cases are similar to those of Ms. Willenberg and the Esperanza Patient.

“We do think there are more out there,” Dr. Yu said in an interview.

Asked whether we’re still far away from applying these one-off cures to the millions of people taking HIV treatment daily, Dr. Yu responded, “We might be close. That’s the beauty of scientific discovery. We don’t know, but that’s why we need more engagement of the community and care providers to help us.”

The research was funded by the Bill and Melinda Gates Foundation and the National Institutes of Health. Dr. Yu and Dr. Dieffenbach have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It sounds like a fairy tale steeped in HIV stigma: A woman wakes up one morning and, poof, the HIV she’s been living with for 8 years is gone. But for a 30-year-old Argentinian woman from the aptly named village of Esperanza, that’s close to the truth, according to an article published in Annals of Internal Medicine.

The woman, the so-called Esperanza Patient, appears to be the second person whose immune system cleared the virus without the use of stem cell transplantation. The first was Loreen Willenberg, a California woman who, after living with HIV for 27 years, no longer had replicating HIV in her system. That case was reported last year.

“That’s the beauty of this name, right? Esperanza,” said Xu Yu, MD, principal investigator of the Ragon Institute of Massachusetts General Hospital, the Massachusetts Institute of Technology, and Harvard University, Boston, referring to the Spanish word for “hope.” “This makes us hopeful that a natural cure of HIV is actually possible.”

Two other people appear to have cleared HIV, but only after full replacement of the immune system via stem cell transplantation – the Berlin Patient, Timothy Ray Brown, and the London Patient. Another man, from Brazil, appeared to have an undetectable viral load after receiving intensified antiretroviral treatment plus supplemental vitamin B3.
 

The rarest of the rare

The Esperanza Patient is among a rare group of people living with HIV called elite controllers. These people’s immune systems can control HIV without antiretrovirals. Most elite controllers’ immune systems, however, can’t mount the immune attack necessary to eliminate all replicating HIV from their systems. Instead, their immune systems control the virus without affecting the reservoirs where HIV continues to make copies of itself and can spread.

The Esperanza Patient and Ms. Willenberg, however, appear to be the rarest of the rare. Their own immune systems seem not only to have stopped HIV replication outside of reservoirs but also to have stormed those reservoirs and killed all virus that might have continued to replicate.

The two women are connected in another way: At an HIV conference in 2019, Dr. Yu was presenting data on Ms. Willenberg’s case. At that conference, she met Natalia Laufer, MD, PhD, associate researcher at the Instituto de Investigaciones Biomédicas en Retrovirs y SIDA at the University of Buenos Aires. Dr. Laufer had been studying the Esperanza Patient at the time and asked Dr. Yu whether she and her team at the Ragon Institute could help her sequence the patient’s HIV genome to see whether, indeed, the virus had been spontaneously cleared from the patient’s system.

So that’s what the pair did, in collaboration with several other researchers into cures for HIV. The Esperanza Patient first acquired HIV in 2013, but in the 8 years that followed, results of 10 conventional viral load tests indicated the virus was undetectable (that is, below the level of quantification for standard technology). During that time, the woman’s boyfriend, from whom she had acquired HIV, died of AIDS-defining illnesses. She subsequently married and had a baby. Both her partner and baby are HIV negative. She only received HIV treatment for 6 months while she was pregnant.
 

A fossil record of HIV

Yet, there was still HIV in the woman’s system. Dr. Laufer and Dr. Yu wanted to know whether that HIV was transmissible or whether it was a relic from when HIV was still replicating and was now defective and incapable of replicating. They performed extensive genome sequencing on nearly 1.2 billion cells that Dr. Laufer had taken from the patient’s blood in 2017, 2018, 2019, and 2020, an additional 503 million cells that were from the placenta of the baby she gave birth to in 2020, and 150 million resting CD4 T cells. Proviral sequencing was undertaken of the full DNA of the HIV to detect whether the virus was still intact. The DNA was then analyzed by use of an algorithm and was tested for mutations. The investigators tested the patient’s CD4 cells to determine whether the cells still harbored any latent HIV.

In this way, they conducted a full viral workup using tests that are far more sensitive than the viral load tests the woman had undergone in the clinic. The investigators then assessed the patient’s immune system to see what the various cells of the immune system could tell them about how well her natural immune system could identify and kill HIV. They isolated the Esperanza Patient’s immune cells and subjected those cells to HIV in the lab to see whether the cells could detect and eliminate the virus.

And just to be safe, they checked to make sure there were no antiretroviral drugs in the patient’s system.

What they found was that without treatment, her CD4 count hovered around 1,000 cells – a sign of a functioning immune system. DNA sequences revealed large chunks of missing DNA, and one sequence had an immune-induced hypermutation. In total, seven proviruses were found, but none were capable of replicating. The CD4 cells they evaluated showed no evidence of latent HIV.

In other words, they had uncovered a fossil record.

“These HIV-1 DNA products clearly indicate that this person was infected with HIV-1 in the past and that active cycles of viral replication had occurred at one point,” Dr. Yu and colleagues write in their recent article.

What may be more useful to researchers looking to turn this spontaneous cure into treatment for millions of people living with active HIV was the evidence that the woman’s immune system had trained itself to attack HIV through a number of genetic mutations. What they found, the researchers write, was evidence of “an incomplete seroconversion” – that is, when the patient was acquiring HIV, the infection was stopped in its tracks.

Yet, Dr. Yu and colleagues say that they can’t prove that the woman is fully cured of HIV.

“Although this might sound unsatisfying, it reflects an intrinsic limitation of scientific research,” they write. “Scientific concepts can never be proved through empirical data collection; they can only be disproved.”
 

There are more out there

Are these women the only ones to have spontaneously cleared HIV? That’s the question, said Carl Dieffenbach, PhD, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. Just like they can’t disprove that the women cured themselves, they can’t prove that she and Ms. Willenberg are the only two people to have experienced this cure.

“We’re all struggling with this,” Dr. Dieffenbach told this news organization. “The goal is to get enough of these people so maybe there’s a road map to how to induce, trigger, change immunity. But this could well be a unique event at the time of initiation of infection. We just don’t know.”

What is needed, Dr. Yu said, is for clinicians to reach out to them regarding cases that could mimic the cases of Ms. Willenberg and the Esperanza Patient. Elaborate testing could then be conducted to see whether these cases are similar to those of Ms. Willenberg and the Esperanza Patient.

“We do think there are more out there,” Dr. Yu said in an interview.

Asked whether we’re still far away from applying these one-off cures to the millions of people taking HIV treatment daily, Dr. Yu responded, “We might be close. That’s the beauty of scientific discovery. We don’t know, but that’s why we need more engagement of the community and care providers to help us.”

The research was funded by the Bill and Melinda Gates Foundation and the National Institutes of Health. Dr. Yu and Dr. Dieffenbach have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It sounds like a fairy tale steeped in HIV stigma: A woman wakes up one morning and, poof, the HIV she’s been living with for 8 years is gone. But for a 30-year-old Argentinian woman from the aptly named village of Esperanza, that’s close to the truth, according to an article published in Annals of Internal Medicine.

The woman, the so-called Esperanza Patient, appears to be the second person whose immune system cleared the virus without the use of stem cell transplantation. The first was Loreen Willenberg, a California woman who, after living with HIV for 27 years, no longer had replicating HIV in her system. That case was reported last year.

“That’s the beauty of this name, right? Esperanza,” said Xu Yu, MD, principal investigator of the Ragon Institute of Massachusetts General Hospital, the Massachusetts Institute of Technology, and Harvard University, Boston, referring to the Spanish word for “hope.” “This makes us hopeful that a natural cure of HIV is actually possible.”

Two other people appear to have cleared HIV, but only after full replacement of the immune system via stem cell transplantation – the Berlin Patient, Timothy Ray Brown, and the London Patient. Another man, from Brazil, appeared to have an undetectable viral load after receiving intensified antiretroviral treatment plus supplemental vitamin B3.
 

The rarest of the rare

The Esperanza Patient is among a rare group of people living with HIV called elite controllers. These people’s immune systems can control HIV without antiretrovirals. Most elite controllers’ immune systems, however, can’t mount the immune attack necessary to eliminate all replicating HIV from their systems. Instead, their immune systems control the virus without affecting the reservoirs where HIV continues to make copies of itself and can spread.

The Esperanza Patient and Ms. Willenberg, however, appear to be the rarest of the rare. Their own immune systems seem not only to have stopped HIV replication outside of reservoirs but also to have stormed those reservoirs and killed all virus that might have continued to replicate.

The two women are connected in another way: At an HIV conference in 2019, Dr. Yu was presenting data on Ms. Willenberg’s case. At that conference, she met Natalia Laufer, MD, PhD, associate researcher at the Instituto de Investigaciones Biomédicas en Retrovirs y SIDA at the University of Buenos Aires. Dr. Laufer had been studying the Esperanza Patient at the time and asked Dr. Yu whether she and her team at the Ragon Institute could help her sequence the patient’s HIV genome to see whether, indeed, the virus had been spontaneously cleared from the patient’s system.

So that’s what the pair did, in collaboration with several other researchers into cures for HIV. The Esperanza Patient first acquired HIV in 2013, but in the 8 years that followed, results of 10 conventional viral load tests indicated the virus was undetectable (that is, below the level of quantification for standard technology). During that time, the woman’s boyfriend, from whom she had acquired HIV, died of AIDS-defining illnesses. She subsequently married and had a baby. Both her partner and baby are HIV negative. She only received HIV treatment for 6 months while she was pregnant.
 

A fossil record of HIV

Yet, there was still HIV in the woman’s system. Dr. Laufer and Dr. Yu wanted to know whether that HIV was transmissible or whether it was a relic from when HIV was still replicating and was now defective and incapable of replicating. They performed extensive genome sequencing on nearly 1.2 billion cells that Dr. Laufer had taken from the patient’s blood in 2017, 2018, 2019, and 2020, an additional 503 million cells that were from the placenta of the baby she gave birth to in 2020, and 150 million resting CD4 T cells. Proviral sequencing was undertaken of the full DNA of the HIV to detect whether the virus was still intact. The DNA was then analyzed by use of an algorithm and was tested for mutations. The investigators tested the patient’s CD4 cells to determine whether the cells still harbored any latent HIV.

In this way, they conducted a full viral workup using tests that are far more sensitive than the viral load tests the woman had undergone in the clinic. The investigators then assessed the patient’s immune system to see what the various cells of the immune system could tell them about how well her natural immune system could identify and kill HIV. They isolated the Esperanza Patient’s immune cells and subjected those cells to HIV in the lab to see whether the cells could detect and eliminate the virus.

And just to be safe, they checked to make sure there were no antiretroviral drugs in the patient’s system.

What they found was that without treatment, her CD4 count hovered around 1,000 cells – a sign of a functioning immune system. DNA sequences revealed large chunks of missing DNA, and one sequence had an immune-induced hypermutation. In total, seven proviruses were found, but none were capable of replicating. The CD4 cells they evaluated showed no evidence of latent HIV.

In other words, they had uncovered a fossil record.

“These HIV-1 DNA products clearly indicate that this person was infected with HIV-1 in the past and that active cycles of viral replication had occurred at one point,” Dr. Yu and colleagues write in their recent article.

What may be more useful to researchers looking to turn this spontaneous cure into treatment for millions of people living with active HIV was the evidence that the woman’s immune system had trained itself to attack HIV through a number of genetic mutations. What they found, the researchers write, was evidence of “an incomplete seroconversion” – that is, when the patient was acquiring HIV, the infection was stopped in its tracks.

Yet, Dr. Yu and colleagues say that they can’t prove that the woman is fully cured of HIV.

“Although this might sound unsatisfying, it reflects an intrinsic limitation of scientific research,” they write. “Scientific concepts can never be proved through empirical data collection; they can only be disproved.”
 

There are more out there

Are these women the only ones to have spontaneously cleared HIV? That’s the question, said Carl Dieffenbach, PhD, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. Just like they can’t disprove that the women cured themselves, they can’t prove that she and Ms. Willenberg are the only two people to have experienced this cure.

“We’re all struggling with this,” Dr. Dieffenbach told this news organization. “The goal is to get enough of these people so maybe there’s a road map to how to induce, trigger, change immunity. But this could well be a unique event at the time of initiation of infection. We just don’t know.”

What is needed, Dr. Yu said, is for clinicians to reach out to them regarding cases that could mimic the cases of Ms. Willenberg and the Esperanza Patient. Elaborate testing could then be conducted to see whether these cases are similar to those of Ms. Willenberg and the Esperanza Patient.

“We do think there are more out there,” Dr. Yu said in an interview.

Asked whether we’re still far away from applying these one-off cures to the millions of people taking HIV treatment daily, Dr. Yu responded, “We might be close. That’s the beauty of scientific discovery. We don’t know, but that’s why we need more engagement of the community and care providers to help us.”

The research was funded by the Bill and Melinda Gates Foundation and the National Institutes of Health. Dr. Yu and Dr. Dieffenbach have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Among active-duty men who have sex with men (MSM), Black and Latino military members are at least three times as likely to be prescribed HIV pre-exposure prophylaxis (PrEP) than their White counterparts, according to new survey results.

“In the civilian population, we see a lot of challenges and barriers to [accessing PrEP] in our high-risk populations – populations in the MSM sphere that are people of color,” study author Colten Staten, RN, a first lieutenant in the army at Walter Reed National Military Medical Center in Bethesda, Md., told this news organization. Because all active-duty service members have free medical care and prescriptions through the Military Health System, the findings demonstrate “what happens when access becomes less of an issue in regard to receiving PrEP prescriptions,” he noted.

The survey, which was presented at the Association of Nurses in AIDS Care 2021 conference, was available for 5 days in 2020. All participants were at least 18 years old, identified as MSM, and were active-duty members of the United States military.

Of the 354 men included in the study, 37.6% were White, 25.4% were Black, 20.3% were identified as Latino, 6.5% were Asian/Pacific Islanders, and 5.6% were Native Americans. In addition, 69.5% identified as gay, 23.4% identified as bisexual, and 7% said they were straight. And 17.2% had a partner who disclosed he was HIV positive, but 19.2% did not know the status of their partner.

Black participants were three times more likely to have been prescribed PrEP than White service members (P < .001). Similarly, Latino respondents were 3.6 times more likely to be prescribed PrEP than their White counterparts (P = .003). Participants whose partner disclosed an HIV-positive status were 7.1 times more likely to receive a PrEP prescription than someone who did not know the status of their partner (P = .013), and bisexual respondents were 2.1 times less likely to have received a PrEP prescription than respondents who identified as gay (P = .04).

While the study demonstrates that at-risk populations are receiving PrEP in the military, research suggests that PrEP is still underprescribed in this population, Mr. Staten said. A 2018 study published in Morbidity and Mortality Weekly Report found that 20.9% of U.S. service members reported a high risk of HIV infection, and an estimated 12,000 individuals in the military qualify for a PrEP prescription. Yet, from Feb. 1, 2014, to June 10, 2016, only 759 service members were prescribed Truvada. The 2018 report found that approximately 350 active-duty service members are diagnosed with HIV every year, with a disproportionate number of new infections occurring in Black individuals.

While the study suggests prescriptions are reaching target populations, “the most concerning finding is that it is not happening in the robust nature that we need,” said Justin Alves, RN, ACRN, CARN, a nurse at Boston Medical Center in Massachusetts who was not involved with the study, in an interview. “This is the start of a lot of research that needs to happen, because not only does the study shed light on people who are serving in the military, but it also sheds light on unique vulnerable populations that we have a hard time capturing and helping in general healthcare settings,” Mr. Alves said.

Mr. Staten agreed that more research is needed to identify additional barriers to care in the military. Additionally, including more information on sexual history in the yearly physical all active-duty service members complete could also help identify more individuals who would benefit from a PrEP prescription.  

“There is no screening for sexual health, as far as the MSM experience,” Mr. Staten said. And he suggested that more questions around sexuality should be included in the screening process. That could help spur more open conversations between patients and providers to bridge gaps in access and care.

Mr. Staten is an active-duty service member. Mr. Alves has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Among active-duty men who have sex with men (MSM), Black and Latino military members are at least three times as likely to be prescribed HIV pre-exposure prophylaxis (PrEP) than their White counterparts, according to new survey results.

“In the civilian population, we see a lot of challenges and barriers to [accessing PrEP] in our high-risk populations – populations in the MSM sphere that are people of color,” study author Colten Staten, RN, a first lieutenant in the army at Walter Reed National Military Medical Center in Bethesda, Md., told this news organization. Because all active-duty service members have free medical care and prescriptions through the Military Health System, the findings demonstrate “what happens when access becomes less of an issue in regard to receiving PrEP prescriptions,” he noted.

The survey, which was presented at the Association of Nurses in AIDS Care 2021 conference, was available for 5 days in 2020. All participants were at least 18 years old, identified as MSM, and were active-duty members of the United States military.

Of the 354 men included in the study, 37.6% were White, 25.4% were Black, 20.3% were identified as Latino, 6.5% were Asian/Pacific Islanders, and 5.6% were Native Americans. In addition, 69.5% identified as gay, 23.4% identified as bisexual, and 7% said they were straight. And 17.2% had a partner who disclosed he was HIV positive, but 19.2% did not know the status of their partner.

Black participants were three times more likely to have been prescribed PrEP than White service members (P < .001). Similarly, Latino respondents were 3.6 times more likely to be prescribed PrEP than their White counterparts (P = .003). Participants whose partner disclosed an HIV-positive status were 7.1 times more likely to receive a PrEP prescription than someone who did not know the status of their partner (P = .013), and bisexual respondents were 2.1 times less likely to have received a PrEP prescription than respondents who identified as gay (P = .04).

While the study demonstrates that at-risk populations are receiving PrEP in the military, research suggests that PrEP is still underprescribed in this population, Mr. Staten said. A 2018 study published in Morbidity and Mortality Weekly Report found that 20.9% of U.S. service members reported a high risk of HIV infection, and an estimated 12,000 individuals in the military qualify for a PrEP prescription. Yet, from Feb. 1, 2014, to June 10, 2016, only 759 service members were prescribed Truvada. The 2018 report found that approximately 350 active-duty service members are diagnosed with HIV every year, with a disproportionate number of new infections occurring in Black individuals.

While the study suggests prescriptions are reaching target populations, “the most concerning finding is that it is not happening in the robust nature that we need,” said Justin Alves, RN, ACRN, CARN, a nurse at Boston Medical Center in Massachusetts who was not involved with the study, in an interview. “This is the start of a lot of research that needs to happen, because not only does the study shed light on people who are serving in the military, but it also sheds light on unique vulnerable populations that we have a hard time capturing and helping in general healthcare settings,” Mr. Alves said.

Mr. Staten agreed that more research is needed to identify additional barriers to care in the military. Additionally, including more information on sexual history in the yearly physical all active-duty service members complete could also help identify more individuals who would benefit from a PrEP prescription.  

“There is no screening for sexual health, as far as the MSM experience,” Mr. Staten said. And he suggested that more questions around sexuality should be included in the screening process. That could help spur more open conversations between patients and providers to bridge gaps in access and care.

Mr. Staten is an active-duty service member. Mr. Alves has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Among active-duty men who have sex with men (MSM), Black and Latino military members are at least three times as likely to be prescribed HIV pre-exposure prophylaxis (PrEP) than their White counterparts, according to new survey results.

“In the civilian population, we see a lot of challenges and barriers to [accessing PrEP] in our high-risk populations – populations in the MSM sphere that are people of color,” study author Colten Staten, RN, a first lieutenant in the army at Walter Reed National Military Medical Center in Bethesda, Md., told this news organization. Because all active-duty service members have free medical care and prescriptions through the Military Health System, the findings demonstrate “what happens when access becomes less of an issue in regard to receiving PrEP prescriptions,” he noted.

The survey, which was presented at the Association of Nurses in AIDS Care 2021 conference, was available for 5 days in 2020. All participants were at least 18 years old, identified as MSM, and were active-duty members of the United States military.

Of the 354 men included in the study, 37.6% were White, 25.4% were Black, 20.3% were identified as Latino, 6.5% were Asian/Pacific Islanders, and 5.6% were Native Americans. In addition, 69.5% identified as gay, 23.4% identified as bisexual, and 7% said they were straight. And 17.2% had a partner who disclosed he was HIV positive, but 19.2% did not know the status of their partner.

Black participants were three times more likely to have been prescribed PrEP than White service members (P < .001). Similarly, Latino respondents were 3.6 times more likely to be prescribed PrEP than their White counterparts (P = .003). Participants whose partner disclosed an HIV-positive status were 7.1 times more likely to receive a PrEP prescription than someone who did not know the status of their partner (P = .013), and bisexual respondents were 2.1 times less likely to have received a PrEP prescription than respondents who identified as gay (P = .04).

While the study demonstrates that at-risk populations are receiving PrEP in the military, research suggests that PrEP is still underprescribed in this population, Mr. Staten said. A 2018 study published in Morbidity and Mortality Weekly Report found that 20.9% of U.S. service members reported a high risk of HIV infection, and an estimated 12,000 individuals in the military qualify for a PrEP prescription. Yet, from Feb. 1, 2014, to June 10, 2016, only 759 service members were prescribed Truvada. The 2018 report found that approximately 350 active-duty service members are diagnosed with HIV every year, with a disproportionate number of new infections occurring in Black individuals.

While the study suggests prescriptions are reaching target populations, “the most concerning finding is that it is not happening in the robust nature that we need,” said Justin Alves, RN, ACRN, CARN, a nurse at Boston Medical Center in Massachusetts who was not involved with the study, in an interview. “This is the start of a lot of research that needs to happen, because not only does the study shed light on people who are serving in the military, but it also sheds light on unique vulnerable populations that we have a hard time capturing and helping in general healthcare settings,” Mr. Alves said.

Mr. Staten agreed that more research is needed to identify additional barriers to care in the military. Additionally, including more information on sexual history in the yearly physical all active-duty service members complete could also help identify more individuals who would benefit from a PrEP prescription.  

“There is no screening for sexual health, as far as the MSM experience,” Mr. Staten said. And he suggested that more questions around sexuality should be included in the screening process. That could help spur more open conversations between patients and providers to bridge gaps in access and care.

Mr. Staten is an active-duty service member. Mr. Alves has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.