Treatment as prevention offers opportunities, challenges
Over the last decade, the development of more potent, better-tolerated antiretroviral drugs for the treatment of HIV infection, accompanied by a growing body of research showing both the public health and individual benefits of antiretroviral therapy, have raised optimism that the epidemic could cease to be a global public health threat in the not-so-distant future.
The preventive power of ART — to avert illness and death, to protect uninfected people from acquiring HIV, and to prevent transmission from people already infected with HIV — has made this an exciting time, and propelled talk of “ending AIDS.” But that optimism, in turn, risks overlooking the tremendous challenges and huge unmet needs for resources and services that getting even close to “ending AIDS” will require.
Universal coverage with ART may sound like a single ambitious but attainable concept, but it embodies a series of separate, yet interconnected goals. For people to benefit from treatment, they must be diagnosed, linked to care, started on treatment, adhere to treatment, and be retained in care. Attaining each of those goals has proven to be difficult at every step, but in particular for those most at risk for HIV infection.
In the United States, about 14% of those who are infected do not know it, about one-quarter of those diagnosed are not linked to care within 6 months to 1 year of diagnosis, about half are not engaged in regular care, and yes, while close to 80% of those who are receiving treatment have undetectable viral loads, this only represents slightly more than 30% of all individuals infected with HIV. The first challenge is timely HIV diagnosis, before the person develops symptoms or has a significant drop in their CD4 count. While patients across the globe are averaging earlier treatment initiation than patients in their settings did a decade ago, across the board they still are not starting as early as they should be, and those in high-income settings still have a great lead over patients in low-income settings. Remaining in care is a challenge around the world, with sharp drops in retention after as little as 1 year of treatment. Furthermore, the percent with long-term viral suppression also decreases over time.
Realizing the full benefits of treatment will mean overcoming the barriers that stand before each step. We know that active steps to link newly diagnosed patients to care are more effective than passive referrals. We know that greater use of case-management services is directly linked to improved retention in care. We also know that access to mental health services, substance abuse services, transportation and housing assistance can be pivotal to successful HIV treatment.
Worldwide, patients face similar challenges with even greater impacts, as well as additional challenges that are deeply rooted in economic and social issues spanning weak health systems, poverty, and discriminatory laws, policies and practices.
While 15 million people receive ART now, an estimated 37 million people live with HIV, and approximately 2 million new infections occur each year worldwide. Weak health systems that already struggle to meet the needs of their current patient populations are now challenged to provide treatment to double the current numbers on therapy. At the same time, funding to fight the epidemic globally has been flat over the last several years and is actually dropping in the U.S. — the world’s largest HIV donor — while low-income countries remain dependent on external support to fight their epidemics.
Given these challenges, more needs to be learned about how to reach, diagnose, link to treatment and retain more people living with HIV with the same amount of funding and fewer new resources. Wider-scale structural changes to health care systems that facilitate access, task shifting and implementing lean strategies will be necessary. Promising approaches to facilitate case management and patient-provider interaction, including through text messaging or social media, will be important. Most importantly, the root causes of the stigma that still surround HIV after more than 3 decades and that keep patients from getting tested or accessing care must be better understood and confronted.
These are some of the realities standing between the question of whether we can treat our way out of the epidemic and an affirmative answer. In reality, ending HIV as a global public health threat will take all the tools we have, including access to sterile syringes as well as opioid substitution therapy for people who inject drugs, treatment for sexually transmitted infections, access to medical circumcision, and pre-exposure preventive use of antiretroviral drugs. Realistically, it will also take the tools we still do not have, and therefore research and development of effective microbicides and eventually a cure or a vaccine is still needed and must be supported.
The HIV epidemic reminds us of the inexorable link between health and human rights, and thus addressing social determinants such as poverty, lack of education, domestic violence and food insecurity among others is just as important as scaling up HIV treatment.
Can we treat our way out of the epidemic? Not today, given the current barriers, and not without every other tool at our disposal. In the meantime, confronting and overcoming the challenges to getting and staying in treatment is essential to improving the lives of people living with HIV, and reducing the number of people who will need treatment in the future. The efforts that go into accomplishing these goals will not only be effective against HIV, but will make for a better world that is better prepared to confront future health threats. Finally, continued advocacy and adequate resources for the global response, so that effective interventions available now can be implemented, and for research, are vital to getting the job done domestically and globally.
- UNAIDS. Fact sheet 2015. http://www.unaids.org/en/resources/campaigns/HowAIDSchangedeverything/factsheet. Accessed February 19, 2016.
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- Carlos del Rio, MD, is chairman of the HIV Medicine Association, chairman of the Hubert Department of Global Health at the Rollins School of Public Health, and professor of medicine in the division of infectious diseases at Emory University School of Medicine.
Disclosure: del Rio reports no relevant financial disclosures.