A new commentary from NIAID experts suggests that we already possess many of the tools necessary to end the HIV epidemic, but that improving implementation is essential.
Despite progress in decreasing HIV mortality and transmission, there are still obstacles to ending the HIV pandemic globally and in the United States.
The past 4 decades of biomedical research have yielded the development of highly effective “toolkits” for preventing and treating HIV. Experts from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, have published an analysis explaining that further success will require optimization of existing interventions and continuous development of innovative approaches to prevent further transmission.
The commentary, published in Clinical Infectious Diseases, highlighted gaps between the health care community’s theoretical ability to end the HIV epidemic and the reality of implementation.
The availability of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) make ending the epidemic a greater possibility from a technical standpoint, but investigators pointed out that progress has been slow. Authors pointed out that “global HIV incidence has declined less than 2% per year since 2010” and wrote that “despite the availability of proven modalities of treatment and prevention, there were 1.7 million new HIV infections and 770 000 deaths from AIDS-related illnesses globally in 2018; an estimated 37.9 million people were living with HIV at the end of the year.”
The commentary highlighted a significant treatment gap: of the 37.9 million people who were living with HIV at the end of 2018, 14.6 million were not on an ART regimen. NIAID experts also reported that PrEP is “vastly underutilized,” given only 475,000 users globally as of April 2019, a number which does not meet the United Nations target of 3,000,000 users by 2020.
The authors highlighted a variety of adherence challenges interfering with ART uptake, such as housing deficits, drug toxicity, stigma, substance abuse, and discrimination. They explained that even simply taking a pill on a daily basis could be challenging for the psychological reason that it serves as a daily reminder that one is living with HIV. Therefore, they recommend further development of approaches that achieve durable control of the virus without the need for daily ART. Approaches in this area range from a “cure” which eradicates HIV from the body to long-acting ART that could be taken intermittently. Authors also saw potential in the development of broadly neutralizing antibodies that could be dosed once every few months, long-acting injectables and implants, and a preventative HIV vaccine.
Even setting aside further development in medicine itself, investigators pointed to evidence that existing treatment and prevention tools could be better utilized. As a model, they noted that San Francisco has had success with the RAPID (Rapid ART Program for HIV Diagnoses) program. Patients are provided 5-day ART starter packs and followed-up with continuous counseling and psychosocial support. From 2006 to 2018, new HIV diagnoses in San Francisco declined by 63%, and the RAPID program saw 96% of patients enrolled between 2013 and 2017 achieve viral suppression despite high occurrence of housing and mental health issues.
Altogether, the commentary from NIH experts suggests that it is essential to both invest in the discovery of new approaches and to better implement existing interventions. Key tools to curb and eventually eliminate the HIV epidemic may already exist, with more in development. The challenge will be to conduct efforts which really reach populations that face barriers to treatment.