A NEW PREVENTION OF CONTROLING HIV.
After decades of
focusing almost exclusively on treating HIV, public health experts are now
considering a new approach, moving to establish more effective prevention
strategies to curb spread of the disease. Recent tests show that anti-HIV drugs
that can hamper the growth of the virus responsible for AIDS may also prevent
progression of the disease if given to infected individuals soon after
their exposure to HIV. The same drugs can also prevent
infections from taking hold among healthy people who are exposed to the
virus; both approaches would be critical ways of controlling spread of the
virus and keeping new cases of HIV to a minimum.
With this
potential in mind, the U.S. Preventive Services Task Force (USPSTF) issued a
draft recommendation urging that all people between the ages of 15 and 65 be
tested for the virus as part of routine health screening, even if they are not
at high risk of exposure to HIV.
The independent
panel of health experts examined recent scientific evidence, including trials
that aimed to use anti-HIV drugs to prevent the disease (so-called pre-exposure
prophylaxis), and concluded that prompt diagnosis leads to earlier use of effective treatments
— and more promising outcomes. Their conclusion: Making HIV screening as
routine as cholesterol testing will allow more people to know their status and
take advantage of favorable therapies. One in five people living with HIV in
the U.S. are not aware
of their positive status, and even among those at higher risk, such as gay and
bisexual men, testing rates are low: nearly 75% had received medical care but
48% were not tested for HIV, according to the Centers for Disease Control
(CDC).
The task force released a draft of their recommendation
proposal, which is open to public comments through December 17. The new
guidelines recommend doctors screen individuals over age 15 and under 65
as well as all pregnant women. “Screening individuals between ages 15 and
65 is likely to improve the health of the population because it’s going to find
people that don’t know they’re positive,” says Dr. Virginia Moyer, the chair of the
task force and pediatrics professor at Baylor College of Medicine. “What we
didn’t know when we made our previous recommendation that we know now is that
treatment earlier in the course of the infection can substantially improve
outcomes.”
That knowledge
is helping public health campaigns to adopt more prevention strategies and
shift away from focusing primarily on treatment as the way to stop the spread
of HIV. And it provides campaigns leverage to promote measures beyond
safe sex and abstinence, which have only been marginally effective in reducing
new infection rates. “The fact is that the best way to deal with HIV is don’t
get it in the first place,” says Moyer. “Yes, we can screen and treat, and it
makes a difference, but it still involves treatment that if you could avoid it,
you wouldn’t want to have. If we can really focus on
Since 2006, the
CDC has pushed for more widespread HIV testing for patients as young
as 13, citing the fact that many are unaware they are living with HIV, and that
available therapies can extend their lives, especially if begun early. In
2005, the task force recommended screening for adolescents and adults who were
at a high risk for HIV. But it wasn’t until 2011, when the latest studies on
the power of AIDS drugs to prevent infection were released, that health
officials could begin devising practical ways of making prevention a priority.
“We started looking at getting treatments before symptoms and it turns out it
does improve things,” says Moyer. “Our treatments have gotten better and
they’ve gotten easier. All those things have worked together to change the
balance so that it now appears that general screening makes it likely that
across the whole population we will have healthier people.”
According
to Kali Lindsey, director of legislative and public affairs for
the National Minority AIDS Council (NMAC), which provides information and
research to public health clinics, the recent trial results, and the USPSTF
recommendation represent a critical change in managing HIV. “Despite decades of
behavioral interventions, infection rates have remained relatively stable, and
are increasing among gay and bisexual men, especially young black gay men,”
says Lindsey. “Treatment as prevention, pre-exposure prophylaxis, and
microbicides offer exciting new ways to slow the spread of HIV. But no
prevention strategy can truly be effective without an expanded push for
scaled-up HIV screening.”
The shift in
emphasis toward prevention is timely as well, since combination drug therapies
have created a sense of complacency about the disease that continues to fuel
50,000 new infections each year even in the U.S. About 20%
to 25% of people living with HIV are unaware they are HIV positive.
“The general
sense of urgency around HIV/AIDS seems to have dissipated,” says Lindsey. “Much
of this has to do with improvements in treatment that have made it possible for
those who can access it to live long, relatively healthy lives. But some
of this also has to do with a perception that has persisted since the onset of
the epidemic–that HIV is a disease of ‘others.’ That it only affects gay men or
injection drug users. Too many people underestimate their own vulnerability to
infection.”
That might
change if testing for HIV became routine. “I don’t think most Americans realize
how serious this epidemic remains,” says Chris Collins, vice president and
director of public policy for amfAR, The Foundation for AIDS Research. “The
good news is we have the tools, including testing, treatment and targeted
prevention that could really begin to end this epidemic in America. The question
is whether we get those interventions to the people who need it.”
Testing for HIV
is the first step toward expanding those interventions. “This recommendation
and its approval will be one more important step towards reducing the stigma of
HIV testing both for people in the general public so they are more likely to
get a test, and for healthcare providers who currently don’t offer the
test automatically because they don’t perceive their client to be at
risk, or they don’t want to talk about sex and sexuality,” says Collins.
Collins say
normalizing testing and making it an active part of quality medical care will
greatly expand the reach of testing and identify more people in need
of treatment. As part of a preventive health care strategy, the
routine HIV testing would be reimbursed by insurers under President Obama’s
proposed health care program; currently only those at highest risk are not
required to provide a co-pay for the HIV test. “We have to make sure it is
reimbursed in all cases so that financial concerns never stand in the way of a
doctor offering a test and person accepting it,” Collins says. “This proposal
is an important step towards that.”
Recent
developments, like the first at-home HIV test OraQuick–which can identify antibodies that
signal HIV infection from saliva in 20 minutes–also helps reduce stigma around
the disease. “Any development that normalizes HIV testing is exciting,” says
Lindsey. “The last couple of years have brought a number of exciting
developments in our fight against HIV. From health care reform and
the National HIV/AIDS Strategy to treatment as prevention and pre-exposure
prophylaxis, science and policy have aligned like never before, making it
possible to realistically envision an end to this epidemic.”
Collins agrees
that the recommendations represent a first step toward turning around the AIDS
epidemic in the U.S. “These policy
changes mean we can really can start to talk about the end of AIDS,” he says.
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