Getting people tested remains top priority in US eradication of HIV
Infectious Disease News spoke with Bruce Olmscheid, MD, HIV specialist at One Medical Group, about current issues regarding HIV treatment in the United States. In this interview, Olmscheid discusses the main challenges of testing those at risk for HIV, the role of a future vaccine and what more can be done to eradicate the disease.
Question: What are the main challenges of enrolling people into HIV care, and what is being done to address those barriers?
Answer: Before we can begin to enroll people into HIV care, they must be tested for HIV. A big challenge to this is that some individuals don’t recognize or are not able to admit that they are in a risk group. Making these individuals self-aware, and getting them to recognize that they need to be tested is a challenge that we collectively need to overcome. While we have made some improvement in some communities, stigma around the disease discourages people from getting testing. But only through testing can people get diagnosed and then put into the care they need.
Q: There are numerous treatment and prevention options available for patients living with HIV and those at risk for the disease. As a physician, to what extent do you rely on a patient’s personal responsibility for their own health?
A: Of course, the patient is ultimately the only one that can bring themselves into a health care setting. But by offering tools and informational resources and by creating a welcoming environment, healthcare systems, doctors and other support groups can help reduce stigma and encourage people to get tested and seek treatment.
Q: Where are we now in the movement toward widespread eradication of HIV, given the treatments available, and what role do you think a vaccine will play in this effort?
A: We have come so far in terms of treatment and prevention, and have taken steps that together can be used to significantly impact the epidemic. We have the potential to really get it under control with the treatments currently available and by using treatment as prevention. Using treatment as a method of prevention refers to our ability treat those who have the infection with drug regimens, and consistently achieve undetectable levels of virus in their blood. Once this has been achieved, the risk of transmitting the virus is reduced so dramatically that we refer to the risk of transmission in this setting as “essentially zero.”
We also have the ability to prevent HIV in those who are HIV-negative by using the drug regimen Truvada [emtricitabine/tenofovir disoproxil fumarate, Gilead Sciences], a pill that the HIV-negative person takes daily. When taken as directed, risk that person acquires HIV reduces to levels nearing 100%. Extensive research is ongoing towards developing additional drugs that can be used in the same convenient way
In Los Angeles, I care for a significant population that is very much on top of the latest treatments and prevention methods described above. I routinely see patients who come in asking for testing and asking about prevention. Having said that, for people who live outside of communities where HIV is discussed routinely, getting to a medical provider and asking for an HIV test is seen insurmountable. For others, the ability to take a medication every single day and come in for blood work every three months is highly inconvenient or difficult. Treatment and prevention have come a long way, but it still is far from what everyone still continues to hope for, which is a vaccine.
In an ideal world where a vaccine exists, you come in and get a vaccine or maybe a series of vaccines. And then, you are immune for life. I think if we ever do develop a vaccine, people would be knocking down the doors to come in to get it.
It is possible to end the epidemic. We can do it biologically with the medications we have. But it will take a tremendous amount of coordination and resources.
Q: To what extent does community engagement help to reach HIV communities and share resources and tools with them?
A: The effectiveness of community engagement depends upon the population that is targeted. In communities like my own in Los Angeles, it’s relatively easy to get folks to show up for a community-based event because the communities are familiar and comfortable with the epidemic. In many instances, they may know someone who’s been affected by HIV. These audiences are more receptive to hearing about HIV prevention and getting tested and are more easily engaged.
Reaching communities that as a whole are not familiar or comfortable with HIV and sexual health is much more challenging. In these areas we can’t host a community engagement event and expect a full house. In my practice, I’ve seen that many individuals are uncomfortable discussing anything related to sexuality, and reluctant to even acknowledge that they may be at risk for STDs such as HIV. Routine HIV testing, as opposed to risk-based HIV testing, will help to identify those who do not feel comfortable asking for the test. Stigma is still so prevalent in many non-urban areas, and in these areas community engagement must be more subtle, for example by putting informational resources out there and by having an ‘open door policy,’ where people can come in, ask questions and get tested in a judgment-free environment. It’s very difficult to get people in the door, but support systems can position themselves in the community in a way that invites engagement.
Q: What are physicians and the healthcare community doing to improve patients’ adherence to HIV treatment?
A: A lot has been done in terms of drug development that makes regimens easier to tolerate and take as directed. The key to successful treatment of HIV has always focused on the need for high levels of adherence over the long haul. Almost all of the medications currently being prescribed for HIV treatment are one pill, once a day. When I was working at Gilead in the 1990s we took two individual HIV drugs and combined them into one tablet — Truvada. Then, working as a joint venture with Gilead and Bristol-Myers Squibb, we took Sustiva [efavirenz, Bristol-Myers Squibb], co-formulated it with Truvada all into one pill. It was the first single-tablet regimen for HIV, and it was revolutionary. By putting all three of those drugs in one tablet, it has dramatically increased patients’ ability to adhere to their entire regimen by taking that one pill every day.
Additional drugs and drug combination regimens have lead to continued improvement in our treatment regimens. Well over 90% of patients on treatment are now able to achieve and maintain viral suppression. Patients are now consistently able to achieve viral suppression well over 90% year after year.
How can physicians help? It’s critical that physicians stress the importance of taking the medication as directed every day. Missed doses increase the risk of the virus developing resistance to the drug. Physicians need to point that out. If you miss your blood pressure medication for a while, you can just go back on it. You may not be able to do with HIV medications.
Q: Considering the treatments currently available, what improvements can be made to enhance physicians’ current armamentarium against HIV?
A: Our regimens have indeed become much easier for patients to take and result in a very high proportion of patients having ongoing viral suppression consistently. Newer medications in development for treatment of HIV seek to improve on long-term side effects of some of the current medications (bone mineral density, kidney function). Research continues to identify ways in which we can ideally reach the viral reservoir and “cure” HIV.
Q: How has the role of the general practitioner changed in the treatment of patients living with HIV?
A: HIV care has always involved general practitioners or primary care providers. Now more than ever, as medications have gotten easier to use, and patients are living and developing other chronic conditions, it is imperative that we train and educate new primary care providers to be comfortable with the care and management of HIV, just as they care for patients with hypertension or diabetes.
For more information:
Bruce Olmscheid, MD, can be reached at firstname.lastname@example.org.
Disclosure: Olmscheid reports no relevant financial disclosures.