Although vertical (mother to child) human immunodeficiency virus (HIV) transmission has been virtually eliminated in the United States,1 HIV incidence in adults has not been reduced,2 and HIV prevalence has increased as a result of case finding and the survival benefits of antiretroviral therapy (ART). In addition, a very substantial proportion of patients with HIV infection—at least 25% according to Centers for Disease Control and Prevention estimates—do not know their status. Consequently, most people with HIV continue to present to care with low CD4 count at the time of diagnosis, reflecting greatly delayed diagnosis and advanced HIV disease. People who do not know whether they have HIV infection and remain untreated can be expected to contribute substantially to ongoing transmission of infection.
Accordingly, identifying people with HIV infection is critical for optimal treatment and prevention. And a person with unrecognized HIV infection has sexual partners who require urgent evaluation as well. In this issue of STD, Katz et al.2a describe the results of a survey that compares partner services offered after a new diagnosis of HIV in 48 health departments in 10 states. The partner of the index case de facto falls into following 3 categories: HIV negative, established (chronic) HIV infection, and early or acute HIV infection (a status not included in this study). The health departments surveyed reported interviewing 10,922 persons with HIV infection (only 43% of all the 26,000 new cases detected) and these people provided information on 10,498 exposed partners. Of exposed partners, 21% already knew that they were HIV infected, 8% were newly diagnosed with HIV infection, 32% were HIV-antibody negative (excluding established infection); 39% of partners were contacted but refused HIV testing or did not have an outcome recorded. Both in 2001 and 2006, public health staff interviewed almost 14 people to diagnose a single case of HIV. The management of the patients or their partners with a new diagnosis of HIV-their “linkage to care” - is unknown.
While these results were collected in 2006, it seems unlikely that dramatic changes have ensued, although recommendation and attitudes have certainly changed. In 2008, the Centers for Disease Control and Prevention released new guidelines emphasizing “HIV Partner Services.”3 The HIV prevention community has become increasingly focused on HIV transmission in discordant partnerships (which are strongly represented in these results). In addition, it is widely believed that earlier ART has personal health benefits4 and that effective ART can reduce the sexual transmission of HIV.5 These ideas have driven mathematical models that suggest that we might literally “treat our way” out of the HIV epidemic.6 Indeed, a series of HIV “test and treat strategies” have been developed and a National Institutes of Health funded study—HIV Prevention Trials Network 065—is scheduled to move forward in the United States.7 In the latter study, very intensive case finding will be wedded to strategies to assure that patients are linked to health care.
Given these health care movements, several shocks need to be absorbed. First, the results of the report by Katz et al.2a while focusing on improvement in Partner Services, identify a massive hole in public health. In 2006, fewer than 20% of exposed partners of newly diagnosed HIV cases had HIV testing (or were offered the opportunity for testing). Additionally, some small number of exposed partners will have been acutely infected. These acutely infected partners are likely very contagious and may contribute disproportionately to HIV transmission within their social networks.8 However, a search for patients with acute infection is missing in most states. Second, we do not know whether patients or their partners get proper counseling and care, or whether they follow through with care. Furthermore, the global economic crisis has left many states without funds to provide HIV therapy to patients who are uninsured at the very time when US guidelines have relaxed the indications for initiation of antiretroviral therapy.9
Where do we go from here? The work by Katz et al.2a identifies 3 key areas for improvement: (i) linking patients to Partner Services through surveillance and name based reporting; (ii) providing Partner Services to those diagnosed outside of public health settings with a better understanding for the role of community based organizations10; and (iii) linking patients and partners to medical care. Rapid and seamless provision of Partner Services for contact tracing and testing—and provision of patient care for those who are infected—makes fiscal, ethical, and public health sense. Patients who know their status are less likely to engage in risky behaviors.11 Patients who are diagnosed early in their disease are more likely to live longer and better quality lives. And counseling and treatment is likely to reduce secondary HIV transmission.5 Partner Services are the most efficient way to find people with unrecognized HIV infection, and the results reported by Katz et al.2a drive home a point that has been made over and over again10 if we are serious about managing HIV in the United States we simply must do a better job with partners.
1. Centers for Disease Control and Prevention. HIV/AIDS surveillance reports. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2007.
2a. Katz DA, Hogben M, Dooley SW, et al. Increasing public health partner services for human immunodeficiency virus: results of a second national survery. Sex Trans Dis 2010;37:469–475.
2. Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA 2008; 300:520–529.
3. Centers for Disease Control and Prevention. Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection. MMWR Recomm Rep 2008; 57(RR09):1–63.
4. Zwahlen M, Harris R, May M, et al; the Antiretroviral Therapy Cohort Collaboration. Mortality of HIV-infected patients starting potent antiretroviral therapy: Comparison with the general population in nine industrialized countries. Int J Epidemiol 2009; 38:1624–1633.
5. Cohen MS, Gay C. Treatment to prevent transmission of HIV-1. Clin Infect Dis 2010; 50:S86–S95.
6. Granich RM, Gilks CF, Dye C, et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: A mathematical model. Lancet 2009; 373:48–57.
8. Pinkerton SD. Probability of HIV transmission during acute infection. AIDS Behav 2008; 12:677–684.
10. Begley EB, Oster AM, Song B, et al. Incorporating rapid HIV testing into partner counseling and referral services. Public Health Rep 2008; 123:126–135.
11. Crepaz N, Lyles CM, Wolitski RJ, et al. Do prevention interventions reduce HIV risk behaviors among people living with HIV? A meta-analytic review of controlled trials. AIDS 2006; 20:143–157.