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Ending the HIV epidemic by 2030 requires immediate action

Messer, Casey DHSc, PA-C, AAHIVS; Baker, Jonathan PA-C

Journal of the American Academy of Physician Assistants: December 2019 - Volume 32 - Issue 12 - p 8–9
doi: 10.1097/01.JAA.0000604876.58358.ed
Commentary
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Casey Messer is an HIV specialist and Ryan White Program Director in the community services department of Palm Beach county government in West Palm Beach, Fla. Jonathan Baker is director of clinical research at Laser Surgery Care and the New York City District Director for the New York State Society of PAs. The authors have disclosed no potential conflicts of interest, financial or otherwise.

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In his 2019 State of the Union address, President Donald J. Trump announced a commitment to end the HIV epidemic in the United States within 10 years. The initiative would use existing programs in the US Department of Health and Human Services (HHS) to target geographic areas disproportionately affected by HIV, with a goal to reduce new HIV infections by 75% in 5 years and at least 90% in 10 years.1 Achieving success in this initiative will require an immediate, substantial, and persistent response to each of the following key strategies:

  • Diagnose all patients with HIV as early as possible. Patients ages 13 to 64 years in all clinical settings must be provided routine, opt-out, laboratory-based antigen/antibody combination HIV screenings, with annual rescreening provided to gay/same-gender-loving, bisexual, and other men who have sex with men (MSM).2,3 Strong considerations for more frequent HIV screening (for example, every 3 to 6 months) of patients living in areas of high HIV incidence, particularly jurisdictions targeted by this initiative, should replace HIV testing based solely on perceived or reported risk factors. In 2017, HIV incidence rates were highest in the South, and accounted for most infections in the United States; black Americans, who account for 13% of the US population, were disproportionately burdened with 43% of HIV diagnoses, despite a lower incidence of high-risk behaviors.4,5
  • Treat HIV infection rapidly and effectively to achieve sustained viral suppression. A shortage of treatment providers and resources prevent newly diagnosed persons from accessing care in a timely manner, with some waiting months for an appointment with an HIV specialist. HIV cannot be sexually transmitted from a patient who maintains an undetectable viral load (a concept known as undetectable=untransmittable, or U=U).6,7 Widespread implementation of test and treat models providing access to antiretroviral therapy within 72 hours of HIV diagnosis would reduce the timeline to achieving viral suppression and minimize the window of potential transmission. New York City's sexual health clinics have shown that immediate initiation of antiretroviral therapy at the time of diagnosis resulted in high rates of linkage to care (84%) and rapid viral load suppression (87% among those with follow-up viral load testing).8 The US Health Resources and Services Administration (HRSA) could increase capacity of the HIV workforce by designating funded jurisdictions as health professional shortage areas, letting medical providers in the Ryan White HIV/AIDS Program qualify for scholarships and student loan repayment through the National Health Service Corps.
  • Prevent new HIV transmissions by using proven interventions, including preexposure prophylaxis (PrEP) and syringe services programs. The FDA approved emtricitabine/tenofovir disoproxil fumarate in 2012 as the first oral medication indicated to reduce the risk of HIV infection. Seven years later, awareness, access, and uptake of HIV PrEP is inadequate. Further, use disparities have emerged along racial and ethnic lines, geographic regions, and sexual and gender minorities, widening the social determinant gap in patients with new HIV infections. Only 7% of the estimated 1.1 million patients with indications for PrEP were prescribed in 2016.9 Black and Hispanic patients have the lowest rates of PrEP prescription, and only 27% of the PrEP prescriptions were in the southern states in 2016.9 Access to PrEP services for patients who are uninsured or underinsured is not financially supported by any federal safety net program, with the CDC and HRSA each declining oversight and resource allocations for PrEP. Increasing access to PrEP could be the single most effective strategy to curb the HIV epidemic in the United States, specifically among states that continue to reject expansion of Medicaid. PAs should become as proficient with medical management of HIV PrEP as they are with other common diagnoses such as hypertension, hyperlipidemia, and diabetes.
  • Respond quickly to potential HIV outbreaks. Molecular surveillance identifies patterns of rapid spread of HIV that might otherwise go unrecognized, allowing for swift public health action. States with a substantially rural HIV burden have the most vulnerability to an HIV outbreak and need focused attention to enhance epidemiologic investigations. New HIV diagnoses and associated laboratory results must be promptly reported to local and state departments of health to curb public health emergencies. In areas where HIV and opioid epidemics intersect, modernizing legislation to let PAs prescribe buprenorphine for medication-assisted treatment (MAT), and establishing needle exchange or syringe service programs would enrich long-term risk reduction opportunities.

Effective interventions to end the US HIV epidemic are well established, yet a lack of resources and coordinated effort have resulted in incidence rates unchanged since 2012. If there is hope of reaching the goal of ending the HIV epidemic by 2030, it lies in changes we make today.

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REFERENCES

1. Fauci AS, Redfield RR, Sigounas G, et al Ending the HIV epidemic: a plan for the United States. JAMA. 2019;321(9):844–845.
2. Branson BM, Handsfield HH, Lampe MA, et al Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1–17.
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8. Blank S, Borges CM, Casto MA, et al Getting a jump on HIV: expedited ARV treatment at NYC sexual health clinics, 2017. Conferences on Retroviruses and Opportunistic Infections. 2018; Abstract 1108.
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