Challenges Remain in HIV Care: Public Health Watch Report

As the International AIDS Society’s (IAS) 9th Conference on HIV Science wraps up this week in Paris, recent news regarding treatment of the troubling disease suggests that, in spite of significant accomplishments, challenges remain—particularly given the cloudy future of healthcare, and funding for it, in the United States.

On July 24, 2017, both Contagion^® and The Telegraph reported that a 9-year-old, formerly HIV-positive South African child has “surprised experts” by achieving what has come to be called “long-term remission” following a long period of antiretroviral therapy (ART) discontinuation. Experts were quick to emphasize that the case, while suggesting that HIV treatment may not necessarily be a lifetime consideration, is still rare within the context of the hundreds of ongoing studies involving the disease and its management.

Meanwhile, preliminary findings from the REALITY trial, published in the issue of The New England Journal of Medicine (NEJM) published on July 20, 2017, found potential clinical value for “enhanced antimicrobial prophylaxis” with continuous trimethoprim/sulfamethoxazole plus isoniazid/pyridoxine, fluconazole, azithromycin, and albendazole over standard prophylaxis (trimethoprim/sulfamethoxazole alone) in the treatment of post-ART infection (typically, tuberculosis and/or Cryptococcus), a common challenge in sub-Saharan Africa, where the trial is ongoing.

After randomizing 1,805 patients (some of whom were asymptomatic or mildly symptomatic for HIV), the authors found that, at 24 weeks following ART initiation, the rate of death with enhanced prophylaxis was lower than that with standard prophylaxis (8.9% vs. 12.2%), although these figures increased to 11.0% and 14.4%, respectively by 48 weeks. Notably, patients in the enhanced-prophylaxis group had significantly lower rates of tuberculosis, cryptococcal infection, and/or oral or esophageal candidiasis; however, they found no significant differences between the 2 groups regarding the rate of severe bacterial infection.

As promising as these findings are, though, a related commentary, published in the same issue of NEJM, noted that “the decrease in HIV-associated deaths appears to have plateaued in recent years…A worrisome new trend that has been observed in countries with long-standing HIV treatment programs is an increase in the number of patients who present for care with advanced HIV infection after a period of treatment interruption.”

This latter point is particularly troubling in light of reports suggesting that an executive order signed by President Trump in January, which reinstated the “Mexico City rule,” may have deleterious effects on nongovernmental organizations working in places like Africa, where treatment compliance is already an issue. Aid workers have told The Guardian and other outlets that the restrictions spelled out in the executive order may result in interrupted and/or discontinued services for patients in the developing world with diseases such as HIV. And, as Contagion^® has reported previously, advocates here in the United States have expressed concern about the future of patients with the disease under the proposed new healthcare legislation.

Which puts a recent analysis released by the Centers for Disease Control and Prevention (CDC) in an interesting light. In assessing their HIV testing initiative, which financed testing and treatment referral programs at local clinics, the agency still found issues regarding access to care and treatment compliance, despite significant improvements. Indeed, among the nearly 3,000 youths who received a new diagnosis of HIV infection as part of the agency’s testing program, only 66% were linked to HIV medical care within 90 days of diagnosis, and only 63% were interviewed for partner services—still well short of the national goal for 2020, which seeks to have “at least 85% of HIV-positive persons [referred] to medical care within 30 days of diagnosis.” Worse, the analysis revealed that, among the nearly 2,000 HIV infections identified during the testing program among youths who had been previously diagnosed, 92% of these patients were not in treatment at the time the analysis was performed.

With the proposed budget cuts potentially facing the CDC as a result of the healthcare law reform debate ongoing in Congress, the future of these initiatives—and the successes they’ve achieved—is very much up in the air.

Finally, speaking of money, and the potential impact of the lack thereof, a study published June 19, 2017 in JAMA Internal Medicine experimented with the use of financial incentives to encourage treatment compliance. In the study, patients received $125 gift cards at the time they received positive test results for HIV, and then were given $70 gift cards quarterly if they received ART and remained virally suppressed. The researchers found that those who complied with care (and thus, received quarterly incentives) were more likely to achieve and maintain viral suppression compared with those who did not receive incentives. The proportion of patients with viral suppression was 3.8% higher in the financial incentives group overall, and, among patients not previously consistently virally suppressed, the proportion was 4.9% higher. In addition, continuity in care was 8.7% higher in the incentivized patients.

So, what have we learned? In short: that properly addressing HIV care requires money and innovation—2 things that some believe may be in short supply going forward.

So much for “good news.”

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous healthcare-related publications. He is the former editor of Infectious Disease Special Edition.