Are we any closer to ending HIV by 2030?

In February 2019, President Donald J. Trump asked for a bipartisan committee to end the HIV epidemic in the United States by 2030.

“Scientific breakthroughs have brought a once-distant dream within reach,” Trump said during his State of the Union address in 2019. “My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years. We have made incredible strides, incredible.”

The announcement was met with skepticism by some experts, although they hoped that this initiative would — at the least — lead to aid in the fight against this epidemic that began nearly 40 years ago.

One year later, experts said they have seen progress but are not sure it is enough to achieve the initiative’s goal.

HIV and the ‘brain drain’

Paul A. Volberding, MD
Paul A. Volberding

HIV remains a persistent problem both globally and in the U.S.

In 2016, an estimated 1.1 million Americans were living with HIV. According to the CDC, 14% of these people — or one in seven — did not know they had HIV. In 2018, 37,832 people living in the U.S. and its dependent areas were newly diagnosed with HIV. Men who have sex with men (MSM) accounted for 69% of all new HIV diagnoses in the U.S. in 2018; that same year, 24% of all HIV diagnoses were made in heterosexual men.

Experts have expressed concerns that a depleted HIV workforce could weaken HIV care and the likelihood of meeting 2030 goals as fewer medical trainees enter the field. Research has shown that the supply of health care providers for people living with HIV is not keeping pace with the growth in demand for their services, including one study published in HIV Specialist in 2016 that showed a decrease in the number of HIV providers from 2010 to 2015 despite an increase in demand for their services.

A second study published in 2016 in Clinical Infectious Diseases reported that 11% of HIV care providers at Ryan White HIV/AIDS Program-funded facilities and 4% of HIV providers in private practice planned to leave HIV practice within 5 years. Some senior clinicians have already moved on from clinical practice, taking jobs in industry.

Experts expect the shortages in the HIV workforce to worsen, even as patients with HIV are living longer and require more care.

“We’re going to need more people if we’re going to tackle that ambitious goal,” Infectious Disease News Chief Medical Editor Paul A. Volberding, MD, professor of medicine and director of the AIDS Research Institute at the University of California, San Francisco, said previously. “We have the tools to end it — the treatment and prevention programs work amazingly well, but we need skilled people to deploy them.”

Trump’s initiative

According to HHS, the 10-year federal plan to end the HIV epidemic in the U.S. by 2030 aims to reduce new HIV infections by 75% in 5 years and by 90% in 10 years.

The overall plan focuses on diagnosing all people with HIV as early as possible; treating the infection rapidly and effectively; protecting people at risk for HIV by using prevention interventions; responding rapidly to identify and manage clusters of HIV infection and prevent new infections; and establishing committed local teams called the HIV HealthForce to bolster responses in these targeted areas.

According to HHS, the plan would fund three major areas of action:

l increasing investments in geographic hotspots through existing programs such as the Ryan White HIV/AIDS Program and a new program run via community health centers that will provide medicine to protect persons at highest risk from being infected with HIV;

l collecting data to determine where HIV is spreading the most quickly and steering decision-making for prevention, care and treatment needs at the local level; and

l distributing funds for the creation of a local HIV HealthForce in targeted areas to increase HIV prevention and treatment.

“The tenets on how you end an epidemic are there — and people are working on them,” Nicholas van Sickels, MD, chief medical officer at CrescentCare in New Orleans, told Infectious Disease News. “Some of the most important work is stigma reduction, taking [pre-exposure prophylaxis (PrEP)] to the next level and caring for communities that aren’t typically touched by these efforts, including women and people of color. They haven’t changed. Science has been working on this goal for years; this particular plan just puts a name to it.”

Plan-related progress

Although it has only been a year since Trump announced this goal, experts said they are seeing some progress.

Raghavendra Tirupathi, MD
Raghavendra Tirupathi

“As an HIV physician in a Health Resources and Services Administration (HRSA)-funded, Federally Qualified Health Center, I am definitely seeing a more coordinated effort to increase access to testing and care for our vulnerable, high-risk patients since last year,” Infectious Disease News Editorial Board Member Raghavendra Tirupathi, MD, FACP, medical director for Keystone Infectious Diseases/HIV, chair of infection prevention at Summit Health and clinical assistant professor of medicine at Penn State University School of Medicine, said.

Van Sickels agreed that there has been progress.

“I can tell you that, on the ground, we have internally been able to make some gains. Hopefully in the next year, the bill the president signed on the budget will be released, along with more funds. That, paired with the Ready, Set, PrEP initiative, will take care of some things,” he said.

Shortly after the 2030 initiative was revealed, HHS and Gilead Sciences announced an agreement in which Gilead said it will donate free PrEP for up to 200,000 individuals each year for up to 11 years. HHS told Infectious Disease News at the time that the program would focus on underserved, high-risk and low-income areas. It was later announced the program would be called Ready, Set, PrEP.

“It’s pretty cool,” van Sickels told Infectious Disease News. “Essentially, if you have a social security number, you can go online and get approved in minutes. It makes it easy for clinicians and patients.”

Another aspect of the plan that van Sickels believes has been a success is the additional attention paid to HIV care in the South.

“They’ve been focusing a lot of care in the Southern states. Using research, data and knowledge from community-based organizations, they’re able to reach the groups that aren’t necessarily touched by TV or bus ads, for example,” he said. “These community groups do a really good job. ... In my opinion, that’s exactly what is needed.”

More support, less stigma

Despite the progress that has been made and the ongoing initiatives, experts are unsure if ending the epidemic by 2030 is likely and have called for additional measures to help the plan.

According to Tirupathi, access to PrEP has been an issue, with as few as 10% of eligible patients using it.

“I am hoping the new HHS and HRSA efforts to provide PrEP to those identified at high risk for HIV acquisition will be successful in increasing PrEP access to underinsured and high-risk populations,” he said.

In addition, testing among these high-risk groups, including MSM, people who inject drugs, transgender people and high-risk heterosexuals, needs to be improved, Tirupathi told Infectious Disease News.

“We need to work on removing barriers to testing and treatment, especially among racial minorities and economically and socially disadvantaged groups,” he said, adding that, Medicaid expansion in the South “will be critical in ending the HIV epidemic.”

Van Sickels said he is optimistic that the plan is having a positive impact.

“It’s encouraging to see some things changing. The change is slow, but I am starting to see it,” van Sickels said. “But 2030? I’m just not sure that’s achievable.”

“This is something that requires a lot of trust and vigilance,” he added. “We need those constants to get this done.” – by Caitlyn Stulpin

Disclosures: Tirupathi and van Sickels report no relevant financial disclosures. Volberding reports serving on a data and safety monitoring board for Merck.

In February 2019, President Donald J. Trump asked for a bipartisan committee to end the HIV epidemic in the United States by 2030.

“Scientific breakthroughs have brought a once-distant dream within reach,” Trump said during his State of the Union address in 2019. “My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years. We have made incredible strides, incredible.”

The announcement was met with skepticism by some experts, although they hoped that this initiative would — at the least — lead to aid in the fight against this epidemic that began nearly 40 years ago.

One year later, experts said they have seen progress but are not sure it is enough to achieve the initiative’s goal.

HIV and the ‘brain drain’

Paul A. Volberding, MD
Paul A. Volberding

HIV remains a persistent problem both globally and in the U.S.

In 2016, an estimated 1.1 million Americans were living with HIV. According to the CDC, 14% of these people — or one in seven — did not know they had HIV. In 2018, 37,832 people living in the U.S. and its dependent areas were newly diagnosed with HIV. Men who have sex with men (MSM) accounted for 69% of all new HIV diagnoses in the U.S. in 2018; that same year, 24% of all HIV diagnoses were made in heterosexual men.

Experts have expressed concerns that a depleted HIV workforce could weaken HIV care and the likelihood of meeting 2030 goals as fewer medical trainees enter the field. Research has shown that the supply of health care providers for people living with HIV is not keeping pace with the growth in demand for their services, including one study published in HIV Specialist in 2016 that showed a decrease in the number of HIV providers from 2010 to 2015 despite an increase in demand for their services.

A second study published in 2016 in Clinical Infectious Diseases reported that 11% of HIV care providers at Ryan White HIV/AIDS Program-funded facilities and 4% of HIV providers in private practice planned to leave HIV practice within 5 years. Some senior clinicians have already moved on from clinical practice, taking jobs in industry.

Experts expect the shortages in the HIV workforce to worsen, even as patients with HIV are living longer and require more care.

“We’re going to need more people if we’re going to tackle that ambitious goal,” Infectious Disease News Chief Medical Editor Paul A. Volberding, MD, professor of medicine and director of the AIDS Research Institute at the University of California, San Francisco, said previously. “We have the tools to end it — the treatment and prevention programs work amazingly well, but we need skilled people to deploy them.”

PAGE BREAK

Trump’s initiative

According to HHS, the 10-year federal plan to end the HIV epidemic in the U.S. by 2030 aims to reduce new HIV infections by 75% in 5 years and by 90% in 10 years.

The overall plan focuses on diagnosing all people with HIV as early as possible; treating the infection rapidly and effectively; protecting people at risk for HIV by using prevention interventions; responding rapidly to identify and manage clusters of HIV infection and prevent new infections; and establishing committed local teams called the HIV HealthForce to bolster responses in these targeted areas.

According to HHS, the plan would fund three major areas of action:

l increasing investments in geographic hotspots through existing programs such as the Ryan White HIV/AIDS Program and a new program run via community health centers that will provide medicine to protect persons at highest risk from being infected with HIV;

l collecting data to determine where HIV is spreading the most quickly and steering decision-making for prevention, care and treatment needs at the local level; and

l distributing funds for the creation of a local HIV HealthForce in targeted areas to increase HIV prevention and treatment.

“The tenets on how you end an epidemic are there — and people are working on them,” Nicholas van Sickels, MD, chief medical officer at CrescentCare in New Orleans, told Infectious Disease News. “Some of the most important work is stigma reduction, taking [pre-exposure prophylaxis (PrEP)] to the next level and caring for communities that aren’t typically touched by these efforts, including women and people of color. They haven’t changed. Science has been working on this goal for years; this particular plan just puts a name to it.”

Plan-related progress

Although it has only been a year since Trump announced this goal, experts said they are seeing some progress.

Raghavendra Tirupathi, MD
Raghavendra Tirupathi

“As an HIV physician in a Health Resources and Services Administration (HRSA)-funded, Federally Qualified Health Center, I am definitely seeing a more coordinated effort to increase access to testing and care for our vulnerable, high-risk patients since last year,” Infectious Disease News Editorial Board Member Raghavendra Tirupathi, MD, FACP, medical director for Keystone Infectious Diseases/HIV, chair of infection prevention at Summit Health and clinical assistant professor of medicine at Penn State University School of Medicine, said.

Van Sickels agreed that there has been progress.

“I can tell you that, on the ground, we have internally been able to make some gains. Hopefully in the next year, the bill the president signed on the budget will be released, along with more funds. That, paired with the Ready, Set, PrEP initiative, will take care of some things,” he said.

PAGE BREAK

Shortly after the 2030 initiative was revealed, HHS and Gilead Sciences announced an agreement in which Gilead said it will donate free PrEP for up to 200,000 individuals each year for up to 11 years. HHS told Infectious Disease News at the time that the program would focus on underserved, high-risk and low-income areas. It was later announced the program would be called Ready, Set, PrEP.

“It’s pretty cool,” van Sickels told Infectious Disease News. “Essentially, if you have a social security number, you can go online and get approved in minutes. It makes it easy for clinicians and patients.”

Another aspect of the plan that van Sickels believes has been a success is the additional attention paid to HIV care in the South.

“They’ve been focusing a lot of care in the Southern states. Using research, data and knowledge from community-based organizations, they’re able to reach the groups that aren’t necessarily touched by TV or bus ads, for example,” he said. “These community groups do a really good job. ... In my opinion, that’s exactly what is needed.”

More support, less stigma

Despite the progress that has been made and the ongoing initiatives, experts are unsure if ending the epidemic by 2030 is likely and have called for additional measures to help the plan.

According to Tirupathi, access to PrEP has been an issue, with as few as 10% of eligible patients using it.

“I am hoping the new HHS and HRSA efforts to provide PrEP to those identified at high risk for HIV acquisition will be successful in increasing PrEP access to underinsured and high-risk populations,” he said.

In addition, testing among these high-risk groups, including MSM, people who inject drugs, transgender people and high-risk heterosexuals, needs to be improved, Tirupathi told Infectious Disease News.

“We need to work on removing barriers to testing and treatment, especially among racial minorities and economically and socially disadvantaged groups,” he said, adding that, Medicaid expansion in the South “will be critical in ending the HIV epidemic.”

Van Sickels said he is optimistic that the plan is having a positive impact.

“It’s encouraging to see some things changing. The change is slow, but I am starting to see it,” van Sickels said. “But 2030? I’m just not sure that’s achievable.”

“This is something that requires a lot of trust and vigilance,” he added. “We need those constants to get this done.” – by Caitlyn Stulpin

Disclosures: Tirupathi and van Sickels report no relevant financial disclosures. Volberding reports serving on a data and safety monitoring board for Merck.