Shocking new HIV infection data spur call for major changes
"It's much worse than we thought."
HIV physicians and AIDS activists are calling for major changes in funding and prevention in light of the recent news that the estimated annual HIV infection rate in the U.S. has been off by 40% for about 15 years.
For years, the Centers for Disease Control and Prevention has said that there are about 40,000 new HIV infections nationally and that this number has been stable since the mid-1990s.
The CDC recently revised its estimate, saying the annual new HIV incidence rate has been about 56,000 per year since the late 1990s. The change does not represent a recent increase in new HIV infections, but a revised historical trend, the CDC told HIV/AIDS clinicians, public health officials, and AIDS activists at the International AIDS Society AIDS Conference, held Aug. 3-8, 2008, in Mexico City, Mexico.
"It's much worse than we thought," says Carl Schmid, director of federal affairs for the AIDS Institute of Washington, DC. "Why did our government allow this to happen? We thought 40,000 new infections were too many. We need some government response now."
Specifically, Schmid and other HIV/AIDS activists, physicians, and other clinicians and advocates for action are calling for increased funding for fighting the domestic AIDS epidemic, including money for prevention and treatment.
"These are tough budget times, but hopefully Congress will listen," Schmid says.
One of the areas that is most urgently in need of increased funding is part C of the Ryan White Care Act, which funds medical clinics that care for HIV patients, says Kathleen Clanon, MD, medical director of HIV Access in Oakland, CA. HIV Access was formed by seven different health organizations that have facilities serving HIV/AIDS patients in Alameda County, California. Clanon also is the chair of the Ryan White Medical Providers Coalition, which is part of the HIV Medicine Association of Washington, DC.
"Our main concern is that the number of patients is growing, and the dollars have been static or have declined a little bit," Clanon says.
Clanon's HIV Access program had an 11 % increase in patients last year and 10 % in 2006, despite annual cuts of 2.5 % each of those years. Also, in recent years, there has been a 40 % increase in the patients served by the Part C Ryan White medical providers, Clanon says.
Adding to the problem is the reality that medical care for today's HIV patient is more complicated than it was a decade ago, Clanon adds.
Many HIV patients have co-morbidities, including hepatitis C infection.
"I take care of 400 HIV patients, and of the people I take care, about 37 % of them have hepatitis C in addition to HIV," Clanon says. "Taking care of people with both hepatitis C and HIV is really oppressively complicated."
HIV providers realistically need a $100 million increase in appropriation, based on the increase in patient numbers and the estimated costs of medical care for these increasingly complex cases, she adds. When you add more patients and more complications to the formula and cut out all funding increases for domestic HIV prevention and treatment, it's a recipe for a national public health nightmare, which some say is already the case for HIV-infected African Americans in the United States.
Is this the U.S or Third World?
"There was a [recent] report that compared the number of infections in the U.S. black community to some developing countries, and found the U.S. numbers were higher," Schmid says.
The report, by the Black AIDS Institute of Los Angeles, CA, found that more black Americans are infected with HIV than the total populations of people infected with HIV in seven of the 15 countries served by the United States President's Emergency Plan for AIDS Relief (PEPFAR).1
The report also found that a free-standing Black America would rank 16th in the world in the number of people living with HIV.
If U.S. public health officials and legislators want to end the HIV epidemic, then they need to make major changes to how they're handling HIV care and prevention, one HIV physician says.
The United States needs to focus on HIV testing and treatment as the best available options for preventing HIV transmission, says Michael S. Saag, MD, professor of medicine and director of the University of Alabama Center for AIDS Research in Birmingham, AL. Saag also is on the board of directors for HIVMA.
"The problem in the trenches is that most publicly-funded clinics have been flat funded for 10 years despite a doubling of patients in that time," Saag says.
If the United States truly wants to reduce the HIV infection rate and eventually eradicate the disease, then the best strategy would be to invest in universal HIV screening and early antiretroviral therapy treatment, Saag says.
Right now the only group of HIV-infected patients who routinely are diagnosed while their CD4 cell counts are at 400 are pregnant women, and thst is because of routine HIV testing for this population, Saag explains.
"If I have a pregnant woman and identify her as HIV infected and put her on treatment and then reduce her viral load to 50 copies, then I have reduced the risk of transmission to her child from 25 % to zero," Saag says.
"If we extrapolated that to testing of every person who has HIV who is accessing the health system then we'd get every HIV-infected person into treatment as needed, and their viral loads would be reduced to undetectable," he adds.
There is strong evidence to suggest that HIV-infected patients with undetectable viral loads are not transmitting the virus even if they engage in unprotected sex, Saag and Clanon say.
"I think everyone would agree that if a person with HIV is taking his meds and is undetectable then the chance of his transmitting the virus is much smaller," Clanon says.
This means that the most powerful prevention program available might be to identify and treat all newly-infected HIV patients.
"First, there are a lot of HIV-infected individuals in the United States who don't know their status, and estimates range from 25% to 50% of the total number of people who are infected," Saag says. "The only way they'll know their status is if they're tested for HIV, and then they'll need access to care."
The second point is that most people with HIV are receiving care at public clinics and hospitals since the cost of providing HIV care is too high for the average private practice doctor to manage, Saag notes.
"Often times these patients need ancillary services of counseling, social services, and access to expensive medications," he says. "This is too onerous for the average private practice doctor to do for the amount of reimbursement received."
However, there is a great deal of evidence now that HIV patients who are under such an umbrella of care are unlikely to transmit the virus to anyone else even if they have unprotected sex, Saag says. "The likelihood of transmission is reduced dramatically," he notes. "So if we're going to decrease the number of new infections in the U.S., which the CDC says is higher than 40,000 new patients per year, then, ideally, we need to get everyone who is infected into care so they'll have undetectable virus."
Reference
- Wilson P, Wright K, Isbell MT. Left behind: Black America: A neglected priority in the global AIDS epidemic. Report published by Black AIDS Institute; August, 2008:1-56 [www.blackaids.org]
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