Ninety percent of HIV transmissions linked to people not in care

People who were not retained in care were responsible for more than 90% of the 45,000 HIV transmissions in the United States in 2009, according to CDC researchers.

“Primary care practitioners should know that this is the latest in a growing body of evidence that preventing new HIV infections depends on reaching people who are HIV-positive with testing, care and treatment — health care providers can play a critical role in each of these areas,” Jacek Skarbinski MD, medical officer in the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention (NCHHSTP), told Infectious Disease News.

Jacek Skarbinski MD 

Jacek Skarbinski

Using data from three national HIV data sources, Skarbinski and colleagues estimated the rate and number of HIV transmissions attributable to the estimated 1,148,200 people living with HIV in 2009 who were in one of five consecutive stages of care:

  • infected with HIV but undiagnosed (18.1%);
  • diagnosed with HIV but not retained in care (45.2%);
  • retained in care but not prescribed ART (4.1%);
  • prescribed ART but not virally suppressed (7.2%); and
  • virally suppressed (25.3%).

“By quantifying where HIV transmissions occur at each state of care, we can identify when and for whom prevention and treatment efforts will have the most impact,” Jonathan H. Mermin, MD, MPH, director of the NCHHSTP, said in a press release. “We could prevent the vast majority of new infections tomorrow by improving the health of people living with HIV today.”

Jonathan Mermin 

Jonathan H. Mermin

The results, published in JAMA Internal Medicine, indicated that those who were infected with HIV but were undiagnosed and those who were diagnosed but were not retained in care were responsible for 91.5% of HIV transmissions in 2009. Approximately 30% of new HIV infections were attributed to those who were undiagnosed, suggesting that testing is crucial in stopping HIV transmission.

“Positive or negative, an HIV test opens the door to prevention,” Eugene McCray, MD, director of the CDC’s Division of HIV/AIDS Prevention, said in the release. “For someone who is positive, it can be the gateway to care and the signal to take steps to protect partners from infection. For someone who tests negative, it can be a direct link to important prevention services to help them stay HIV-free.”

Additionally, people who were virally suppressed were 94% less likely to transmit HIV than those who went undiagnosed.

“Health care providers should know that U.S. guidelines now recommend that everyone diagnosed with HIV should get treatment, regardless of their viral load count…” Skarbinski said. “Bottom line: improving the health of people living with HIV is critical for both those with HIV and for those at risk for HIV.”

In a related editorial, Thomas P. Giordano, MD, MPH, of the Michael E. DeBakey VA Medical Center in Houston, said improving testing, linkage to care and retention would present its own challenges.

“Advancing individuals forward from the beginning to the end of the cascade will place a more challenging population on antiretroviral regimens, and fostering their success might require even more supportive resources,” he wrote. “Nonetheless, as demonstrated by Skarbinski et al, the benefits of optimizing treatment to the individual will be magnified on a population basis in preventing new infections.” – by John Schoen

Disclosure: The researchers and Giordano report no relevant financial disclosures.

People who were not retained in care were responsible for more than 90% of the 45,000 HIV transmissions in the United States in 2009, according to CDC researchers.

“Primary care practitioners should know that this is the latest in a growing body of evidence that preventing new HIV infections depends on reaching people who are HIV-positive with testing, care and treatment — health care providers can play a critical role in each of these areas,” Jacek Skarbinski MD, medical officer in the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention (NCHHSTP), told Infectious Disease News.

Jacek Skarbinski MD 

Jacek Skarbinski

Using data from three national HIV data sources, Skarbinski and colleagues estimated the rate and number of HIV transmissions attributable to the estimated 1,148,200 people living with HIV in 2009 who were in one of five consecutive stages of care:

  • infected with HIV but undiagnosed (18.1%);
  • diagnosed with HIV but not retained in care (45.2%);
  • retained in care but not prescribed ART (4.1%);
  • prescribed ART but not virally suppressed (7.2%); and
  • virally suppressed (25.3%).

“By quantifying where HIV transmissions occur at each state of care, we can identify when and for whom prevention and treatment efforts will have the most impact,” Jonathan H. Mermin, MD, MPH, director of the NCHHSTP, said in a press release. “We could prevent the vast majority of new infections tomorrow by improving the health of people living with HIV today.”

Jonathan Mermin 

Jonathan H. Mermin

The results, published in JAMA Internal Medicine, indicated that those who were infected with HIV but were undiagnosed and those who were diagnosed but were not retained in care were responsible for 91.5% of HIV transmissions in 2009. Approximately 30% of new HIV infections were attributed to those who were undiagnosed, suggesting that testing is crucial in stopping HIV transmission.

“Positive or negative, an HIV test opens the door to prevention,” Eugene McCray, MD, director of the CDC’s Division of HIV/AIDS Prevention, said in the release. “For someone who is positive, it can be the gateway to care and the signal to take steps to protect partners from infection. For someone who tests negative, it can be a direct link to important prevention services to help them stay HIV-free.”

Additionally, people who were virally suppressed were 94% less likely to transmit HIV than those who went undiagnosed.

“Health care providers should know that U.S. guidelines now recommend that everyone diagnosed with HIV should get treatment, regardless of their viral load count…” Skarbinski said. “Bottom line: improving the health of people living with HIV is critical for both those with HIV and for those at risk for HIV.”

In a related editorial, Thomas P. Giordano, MD, MPH, of the Michael E. DeBakey VA Medical Center in Houston, said improving testing, linkage to care and retention would present its own challenges.

“Advancing individuals forward from the beginning to the end of the cascade will place a more challenging population on antiretroviral regimens, and fostering their success might require even more supportive resources,” he wrote. “Nonetheless, as demonstrated by Skarbinski et al, the benefits of optimizing treatment to the individual will be magnified on a population basis in preventing new infections.” – by John Schoen

Disclosure: The researchers and Giordano report no relevant financial disclosures.