CDC: HIV risk behaviors on rise while therapies show chink in armor
Experts say it’s time to regain control of epidemic
The HIV epidemic in the United States clearly has been overshadowed in recent months by the frightening statistics and predictions about the African continent’s AIDS war. But before Americans become too complacent with success stories about HIV and the protease inhibitors and other antiretrovirals, they should heed the warning signs apparent in the latest government HIV research.
Studies sponsored by the Centers for Disease Control and Prevention (CDC) in Atlanta raise some alarming questions. Research indicates that antiretroviral therapy does not succeed in all patients, and it must be improved continuously to maintain long-term suppression. CDC investigators also have found much evidence that Americans are not taking the AIDS threat as seriously as they have in the past, which means prevention efforts need renewed and stronger impact on at-risk populations.
"We’ve said all along that these drugs are a cure for no one, and they don’t work for everyone," said Julio Abreu, deputy director of government affairs at AIDS Action in Washington, DC.
While antiretrovirals certainly have brought down the rate of AIDS deaths nationwide, the protease inhibitors and combination therapies haven’t been around long enough for researchers to study the long-term efficacy. Also, no one knows the health effects that the drugs have on people who have been taking them for many years, Abreu added.
"We still believe prevention is the best way to deal with this epidemic," he said. "Prevention costs less, and it’s more humane for folks not to get this deadly disease in the first place."
Together, each of the CDC’s new studies becomes one part of a bigger puzzle that shows how tentative the nation’s control is over the epidemic. The studies, which were presented at the XIII International AIDS Conference in Durban, South Africa, include the following:
• The population of 15- to 20-year-old men who have sex with men (MSM) in the United States has experienced a resurgent HIV epidemic.1
• Highly active antiretroviral therapy (HAART) fails to fully suppress HIV in nearly two-thirds of patients over a 15-month period. The study’s suppression criteria were higher than what is needed to keep patients healthy. However, that also means many patients will have to switch to more complex and expensive regimens to maintain suppression of their viral loads.2
Bisexual men engage in more risky behaviors
• Bisexual males are more likely to engage in risky sexual behavior with men, as well as with women, and are just as likely to have HIV infection. Among MSM, 17% said they recently had sex with both men and women, and 4% had had unprotected sex with both genders. Therefore, bisexual men serve as a bridge for HIV transmission between MSM and women.3
• Women are less likely than men to achieve HAART treatment success. In the CDC study, nearly 30% of women failed to show a significant decrease in viral load after initiating treatment.4
• African-Americans and women are less likely to be prescribed HAART than are white men. Others who are less likely to be prescribed antiretroviral therapy include people who have a history of psychosis, injection drug use, and alcoholism.5
• About 22% of gay and bisexual men ages 15 to 25 have never been tested for HIV, which suggests the need for intervention strategies to increase testing.6
• More than one-quarter of women taking HIV medication were unable to adhere completely to their treatment regimen. The factors correlated with poor adherence were depression, HIV-related stress, loss of family income, and family illness.7
• HIV-infected gay and bisexual men increasingly are engaging in unprotected anal sex. A third of MSM surveyed who engaged in anal intercourse within the past year had done so without protection.8 (See story on increasing risk behaviors, p. 111.)
• For the 25 states that have HIV surveillance data from 1998, the highest rate of African-Americans living with HIV and AIDS was in Jersey City, NJ, and the highest rate of Hispanics living with HIV and AIDS was in Newark, NJ.9
• CDC surveillance data estimate the number of people living with AIDS in the United States through June 30, 1999, to be 308,933, with most of the AIDS cases hailing from the states of New York, California, Florida, and Texas. (See CDC charts on people living with AIDS, p. 107, and the number of reported AIDS cases, p. 108.)
The CDC studies back up other research published in recent months, all of which point to a possible reversal in the trend of decreased morbidity and mortality among HIV-infected Americans.
"We’ve had 90% reductions in both morbidity and mortality since 1996, and those have been sustained," said Scott Holmberg, MD, senior epidemiologist with the CDC’s Division of HIV/ AIDS Prevention.
But that’s only the first half of what has happened since HAART was introduced, Holmberg noted. "The second point is that each successive HAART regimen seems to work less and less long, either because of toxicity or virologic failure," he added.
Complex regimens becoming less effective
Research presented by Holmberg in Durban showed that on average patients stayed on their first HAART regimen less than 11 months before the treatment proves ineffective or intolerable. For patients on the second HAART regimen, suppression lasted about 8.1 months on average, and for patients taking a third HAART regimen, virologic success lasted about 6.4 months on average.10 The study analyzed medical data from more than 1,600 AIDS patients nationwide.
"What that means is more and more complex and expensive regimens are less and less successful in keeping viral loads suppressed and keeping people alive and healthy," he explained. "And the implication is that we must develop new drugs and new strategies before we exhaust the therapeutic armory for HIV."
Holmberg’s study on viral suppression used strict criteria for determining that treatment was a success. The treatment had to produce and maintain one log, a 10-fold or more reduction in viral load, and a constant or increased CD4 cell count. Based on those criteria, the study found that little more than one-third of patients on HAART for at least 15 months had achieved success in suppressing HIV.
"We felt that was clearly a success," he said. "But the fact is there are many people who had half a log reduction in viral load, and their CD4 cell count went up, and they were successful but weren’t included in our analysis of successful patients."
Another CDC study looked at the HAART failure rate within the first five months of therapy for women vs. men. Using a small sample of patients taking HAART for the first time, the study found that women were significantly more likely to have a treatment failure. All participants were assessed to be ready to take HAART, to have a support partner to help them adhere to their regimen, and were not currently abusing illegal drugs.
Women more likely to fail HAART
Nearly 30% of the women failed to show a significant decrease in their viral load after beginning treatment, while only 10% of men failed HAART. Success criteria were at least a two-log drop in viral load or a viral load of fewer than 3000 copies/mL.
"The women who did not show early success tended to be more depressed, reported more stress, had less overall social support, and they had more misconceptions about HAART and how the meds worked," said Linda Koenig, PhD, assistant chief for behavioral science and a clinical psychologist in the Mother-Child Transmission and Pediatric and Adolescent Study Section of the CDC’s Division of HIV/ AIDS Prevention Epidemiology Branch.
The women who were early HAART failures tended to have experienced stress in the prior six months that could have included separation from partner, death of a family member, inability to move when expecting to move, loss of a job, incarceration, or conflict with health care workers.
Koenig said the study shows how important it is to assess new HIV patients for life stresses and other factors before beginning antiretroviral therapy. "Assess them for the need for social services to help them with major life events, for mental health services, particularly in relation to depression, and for education and counseling about HAART," she advised.
Women less likely to adhere with regimen
This research, added to another study showing that women are less likely to be prescribed HAART, show that medical providers have to face some important challenges in reaching women with HIV, said Helene D. Gayle, MD, MPH, director of the CDC’s National Center for HIV, STD, and TB Prevention.
"Findings presented in Durban show that women are less likely to be prescribed HAART and, for those who are, obstacles such as HIV-related stress and income loss can stand in the way of proper adherence," Gayle said. "These results point to the reality that these treatments are complex and are a lifelong proposition."
Health professionals need to recognize that their patients need more than the antiretroviral drugs, she added. "And they must do what they can to make sure their HIV-infected patients are linked to the social and psychological services they need to deal with the reality of living with HIV."
Another CDC researcher took a close look at what factors prevent an HIV-infected woman from adhering to her medication regimen. The study of 520 HIV-infected women eligible for HAART found that only 288 (55%) of the women were taking any antiretroviral drugs.
"What happens is a lot of women who have been prescribed have not taken the meds," said Jan Moore, PhD, assistant chief in the CDC’s Sexual Transmission and Injection Drug Use Section.
Of the 288 women taking HAART, about 26% were unable to adhere completely to their drug regimen. The women who failed to take their drugs regularly were more likely to have depressive symptoms, adverse life events, and HIV-related distress. Factors such as recent illicit drug use, viral load, CD4 cell count, and HIV-related symptoms appeared to have no impact on the women’s adherence.
"It would be helpful if we were doing more to screen for psychological distress, depression, stress, and a number of other factors," Moore says. "Taking a person’s psychological state into account in thinking about how adherent they might be is really important."
References
1. Valleroy L, MacKellar D, Mei JV, et al. High HIV Incidence among 15- to 22-year-old men who have sex with men in 7 U.S. cities. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
2. Holmberg S, Palella F, Moorman A, et al. Correlates of durable treatment success among long-term highly active antiretroviral therapy (HAART) recipients in the HIV Outpatient Study (HOPS). Abstract TuPpB1166. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
3. Valleroy L, Prentiss D, MacKellar D, Secura G. The bisexual bridge for HIV among 15- to 22-year-old men who have sex with men in 7 U.S. cities. Abstract WePeC4300. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
4. Koenig L, Ellerbock TV, Pratt-Palmore M, et al. Predictors of early failure of highly active antiretroviral therapy (HAART). Abstract WePeB4148. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
5. McNaghten AD, Hanson DL, Dworkin MS, Jones JL. Inequities between gender and racial groups in prescription of highly active antiretroviral therapy. Abstract ThPeB5286. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
6. Sumartojo E, Lyles C, Guenther-Grey C, et al. Prevalence and predictors of HIV testing in a multi-site sample of young men who have sex with men. Abstract ThPeD5804. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
7. Moore J, Hamburger M, Schoenbaum E, et al. Predictors of adherence to antiretroviral therapy among HIV-infected women. Abstract WePeD4598. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
8. Denning P, Nakashima AK, Wortley P, et al. Increasing rates of unprotected anal intercourse among HIV-infected men who have sex with men in the United States. Abstract ThOrC714. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
9. Dean-Gaitor H, Wortley PM, Fleming PL. Prevalence of HIV and AIDS among African-Americans and Hispanics in Metropolitan Statistical Areas — United States, 1998. Abstract MoPeC2452. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
10. Holmberg S, Palena F, Moorman A, et al. Continued low morbidity and mortality among patients with advanced HIV infection and their patterns of highly active antiretroviral therapy (HAART) usage. Abstract ThOrC723. Presented at the XIII International AIDS Conference. Durban, South Africa; July 2000.
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