With the upcoming World AIDS Day on 1st December, we are reminded by the National Institutes of Health (NIH) of the work that still needs to be done to end the HIV Epidemic in the United States.
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A key take-home message will be the undetectable equals untransmissible (U=U) concept, which has been endorsed by major health and research organizations globally. The concept is based on the growing body of evidence showing that people who maintain an undetectable viral load in their blood by adhering to their treatment regimen cannot pass the virus onto others.
The President’s commitment to ending the epidemic
During his State of the Union Address earlier this year, President Donald Trump announced his commitment to ending the HIV epidemic in the US.
Subsequently, the US Department of Health and Human Services announced an ambitious initiative called “Ending the HIV Epidemic: A Plan for America.”
The goal of the plan is to reduce the domestic HIV incidence by 75% in five years’ time and by 90% by the year 2030.
The NIH has also announced that it will continue to play a pivotal role in funding and to support the research underpinning this effort. Research funded by the institute has even provided a scientific outline for how achieving an end to the HIV epidemic is indeed feasible.
Over the last three decades, researchers have developed antiretroviral drug regimens that suppress HIV’s ability to replicate. Ongoing refinement over the years has increased the effectiveness of these regimens and significantly reduced side effects. Today, the drugs can be combined into a single pill that a person only needs to take once a day to achieve an almost normal lifespan.
Multiple research studies have shown that using antiretroviral therapy to achieve and maintain an undetectable level of HIV stops an infected person from transmitting the virus. Studies have also demonstrated that this prevention strategy, known as Undetectable = Untransmittable or U=U, can prevent perinatal transmission of the virus.
U=U will be a central message conveyed at World AIDS Day on 1st December.
The general community isn’t up to date with the latest developments and knowledge around HIV. U=U has a lot of meaning for people living with HIV and their families, friends, and support networks… This concept means people can still have a partner, a child, and a normal life expectancy.”
Annie Boulton, Bolton Clarke Clinical Nurse Consultant
People who are HIV-negative, but at risk of infection can also take a single pill daily as pre-exposure prophylaxis or PrEP, which cuts the risk by 99%.
Emergency post-exposure prophylaxis or PEP can also stop HIV from becoming established in the body if it is started within three days of exposure and then taken for a further 28 days.
NIH and its collaborators are also striving to pursue the development of a safe and effective vaccine against HIV, as well as a cure for people who are already living with the disease.
Two major advances towards achieving these aims were announced earlier this year.
Mosaico, the largest clinical trial to date of an investigational HIV vaccine candidate, began in Europe and the Americas. Two other large studies evaluating vaccine efficacy are underway in southern Africa.
Furthermore, the NIH and the Bill & Melinda Gates Foundation have committed to providing at least $100 million in funding to assist in the development of an affordable, gene-based cure for HIV and for sickle cell disease that will be accessible to developing countries.
However, even without these more recent efforts, the HIV prevention “toolkit”, including U=U, PrEP, and PEP, should be sufficient to end the HIV epidemic.
What problems remain?
The challenge that is still faced is that gaps in implementation are preventing people who need these toolkits having access to the interventions that would protect them. Although the incidence of HIV in the US has significantly declined since it peaked in the 1990s, there has been no further reduction in incidence. Despite the availability of the robust HIV prevention toolkit, about 38,000 people in the US were diagnosed with HIV during 2018.
The aim of the “Ending the HIV Epidemic: A Plan for America” is to close these implementation gaps. At the heart of this effort are NIH-funded advances in HIV prevention, diagnosis, treatment, and care.
Furthermore, HHS agencies, health departments, local community organizations, and other organizations will collaborate to drive what is known of as “implementation science,” the aim of which is to determine the best ways to implement these advances. This field of research is essential to ensuring proven tools and techniques are translated into approaches that can be adopted at a community level, particularly among the most vulnerable communities.
On World AIDS Day, another key message will be that ending the HIV Epidemic must take place “community by community.” People with HIV are often from unique communities that are shaped by differences in race, culture, ethnicity, and socioeconomics.
According to the NIH statement on World AIDS day “to reach people who have different needs, preferences, and choices, and ensure that HIV treatment and prevention tools can work in their lives, we must go beyond a ‘one-size-fits-all’ approach.”
“By working directly with health departments and other community organizations, and by hearing the voices of those for whom this effort matters most, researchers can identify the best ways to improve the health of those living with HIV, prevent new cases, and, ultimately, end the epidemic,” the statement concludes.
Eisinger, R.W. et al. (2019). HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. Journal of the American Medical Association DOI: 10.1001/jama.2018.21167 .