World AIDS Day: Addressing the Challenges Ahead in the Fight Against HIV—Special Public Health Watch Report

Friday, December 1, marks the 29th World AIDS Day.

Although much has changed since the first World AIDS Day in 1988—when some 60,000 individuals died from HIV/AIDS and/or related complications in the United States alone—the effects of the disease on public health remain significant, even as more individuals are “living” with the virus, and fewer are dying from it, according to HIV.gov statistics.

A US Centers for Disease Control and Prevention (CDC) Vital Signs report, released November 28, 2017, for example, focused on HIV testing and noted that roughly half of those with the disease have been positive for an average of 3 years before they are diagnosed. Indeed, some 15% of those with HIV in the United States don’t know they have the disease, and CDC figures suggest 40% of all new infections in the country can be traced to these individuals. Still, the report estimates that the average time between infection and confirmed diagnosis in the United States has declined by 7 months since 2011—so progress is being made.

And, among new infections, there has been an improvement in these patients. Data collected by the CDC’s Ryan White HIV/AIDS Program for its annual HIV Surveillance Report suggests that, among cities eligible for funding through the program, New York (10,041), Atlanta (6,688), and Los Angeles (5,690) had the highest number of reported AIDS cases between 2011 and 2015 (the most recent period for which information was available), and that, as of the end of 2015, New York (64,476), Washington (19,184), and Chicago (16,230) had the most “persons reported living with diagnosed HIV infection ever classified as AIDS.” In a second supplement to the HIV Surveillance Report, the Ryan White HIV/AIDS Program found that, in 2015, 21.4% of those newly diagnosed with HIV were classified as Stage 3 (AIDS), and those classified at Stage 3 at diagnosis were more likely to be female than male.

Of course, the stigma that surrounds HIV/AIDS often delays diagnosis and treatment—and, sadly, it doesn’t seem to be fading. The Positive Perspectives survey, which was sponsored and designed by drug-maker ViiV Healthcare, surveyed 1111 individuals living with HIV in 9 countries (Austria, Australia, Canada, France, Germany, Italy, Spain, the United Kingdom, and the United States), and found that roughly 3 in 10 are “generally open about their status” and more than 70% are comfortable discussing their care with their doctors; however, the survey also found that 82% of respondents have “experienced a form of stigma related to their HIV in the 12 months prior to participating.”

“It is… important for health departments, community-based organizations, and others who provide HIV testing to expand HIV testing initiatives and help normalize HIV testing for everyone,” Eugene McCray, MD, Director of the CDC’s Division of HIV/AIDS Prevention wrote in a letter released with the Vital Signs report. “We are closer than ever to achieving a future free of HIV in the United States, and we have the prevention and treatment options to get there. But more HIV testing is needed to make sure those powerful tools are available to people who can benefit from them.”

On the positive side, another CDC analysis, published on October 20, 2017, in the agency’s Morbidity and Mortality Weekly Report, suggests that a federally funded testing initiative has been effective at not only diagnosing Americans with HIV, but encouraging positive patients to seek appropriate treatment. In data gathered from CDC-funded HIV test sites, for 2015, the authors found that 48% of the 3.02 million HIV tests provided were administered to women—and that the highest percentages of those women tested were between 20 and 29 years of age (41%), black (49%). Among newly diagnosed women HIV infection, 61% were linked to HIV medical care within 90 days of diagnosis.

Regarding the issue of access to care globally, Charles W. Flexner, MD, Divisions of Clinical Pharmacology and Infectious Diseases, Johns Hopkins University School of Medicine, in an editorial published in the July 2017 issue of Current Opinion in HIV and AIDS, argued that, in order to improve care rates, clinicians need to focus efforts on effective and accessible (read: low-cost) treatment that can be provided universally. Essentially, he believes that a single, universally acceptable antiretroviral therapy (ART) regimen can remarkably lower the rate of HIV-infected individuals and, possibly, permanently contain the disease on a global scale. Dr. Flexner is co-chairing the 3rd International Conference on Antiretroviral Drug Optimization in Johannesburg on December 1, 2017.

His thoughts on this issue are particularly poignant, given the findings of a study published on November 13, 2017, in JAMA Neurology, in which researchers measured brain changes (using MRI) and cognitive performance in 79 participants, 48 of whom were HIV-positive and receiving ART, and 31 of whom did not have HIV. The authors noted that the adults with HIV had poorer cognition and reduced brain thickness and volume on MRI than adults without HIV, even if they had good viral suppression on ART; however, over the 2-year study period, changes in cognition and brain structure were similar between the 2 groups.

Potential adverse events or not, getting HIV-positive patients into treatment may only be half the battle. In another commentary, published October 26, 2017 in the New England Journal of Medicine, authors Chris Beyrer, MD, MPH, of the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health; and Anton Pozniak, MD, of the Department of Genitourinary Medicine and HIV, Chelsea and Westminster Hospital, London, decried the threat of drug resistance on successful treatment of HIV. Although World Health Organization (WHO)/CDC data cited by the authors indicated that roughly half of the 36 million people worldwide currently living with HIV are receiving ART, they noted that, for the first time, rates of pretreatment drug resistance surpassed 10% in 6 of the 11 countries surveyed by the 2 agencies: Argentina, Guatemala, Namibia, Nicaragua, Uganda, and Zimbabwe. How significant is this?

“Drug resistance is one of the markers of failure of HIV programs,” the authors of the commentary write. “The threat it poses is both that treatment will fail clinically in individual patients and that communities will be at risk from viremic patients whose disease continues to be infectious. Our newest and most effective prevention tool [pre-exposure prophylaxis or PrEP]… is also at risk from HIV drug resistance. More robust drugs with higher resistance barriers may help solve some of these problems. But we will still face the many challenges of logistics, adherence, and… funding required to sustain… massive global treatment effort.”

Indeed, as they conclude, as exciting as it is that half of those living with HIV are currently receiving treatment, that means that the other half aren’t. And so, while there is much to celebrate this World AIDS Day, there is, as always, a call to action—and Contagion® will continue to cover both the good news and the bad until there is no need to include this day on the calendar anymore.

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.