Alex Saenz is a gregarious 27-year-old gay man, but his bubbly exterior hides a rough and tumble life.
The 2009 Eastern High graduate struggled with addiction, specifically meth, a popular sex drug in gay communities across the country, including in Lansing. Saenz said he was injecting the drug, a habit that came to a crashing halt two years ago when a free HIV test registered inconclusive. In his case, the rapid test for the antibodies, which the body develops to fight invaders, was positive. But a confirmatory test taken by oral swab came back negative.
"Something didn't feel right," Saenz said. So he asked his primary care doctor to do a more sensitive blood test. That one came back positive.
He was an elusive target for public health — the newly infected person. When someone is first infected, the virus multiplies rapidly, winning the first battle with the immune system. Eventually, the immune system gets the virus under control. Those in the very early stage, where the immune system is losing the battle, don't test positive for the virus but are highly infectious. Scientists and doctors have found that starting someone on powerful anti-HIV medications shortly after infection can quickly control the virus and set a path to better health.
Saenz takes a combination pill every day. Saenz's medications are paid for by a publicly funded insurance program. The cost is about $14,000 a year for the three drug combination pill he takes.
"It has had no impact on my everyday routine and activity," he said.
The drugs that Saenz takes, and others like it, have changed the face of what was once a fatal diagnosis to one of a chronic manageable disease. Experts say those drugs and new testing technology make them "cautiously optimistic" that the HIV epidemic can be halted in the coming years.
The medications — called antiretroviral medications, or ARVs — have reshaped the HIV epidemic in the U.S. and other developed countries. Before they were approved in 1996, a person diagnosed with HIV faced a significantly shortened lifespan. Today, a person diagnosed with HIV who takes the drugs is expected to live a completely normal lifespan, though with a chronic manageable disease.
Scientists and public health officials have also discovered another benefit related to the use of the drugs. When a person takes the drug daily, it controls the virus — something experts call an undetectable viral load. With that undetectable viral load, a person is highly unlikely to transmit their infection.
The science behind this discovery has spawned a public health movement called Treatment as Prevention (TasP). That movement is now being driven by federal dollars to get people living with HIV into medical treatment and on the drugs. The benefits are two-fold: better health outcomes for the person with HIV and dramatic reductions in onward transmission of the infection.
Also, health officials are recommending the drugs to prevent people who are not infected with the virus from becoming infected. In 2012, the feds approved a drug called Truvada as a daily regimen to prevent HIV infection. Studies have shown that if taken daily the drug is over 92 percent effective.
Even the tests used to identify those with HIV have improved. The new HIV test being used can identify HIV infections as early as 12 days after infection, instead of the minimum 20 days from the last generation of tests.
Despite all these improvements, new HIV infections in the U.S. remain stubbornly at about 50,000 new cases. In Michigan, Ingham County is second in HIV infections to the city of Detroit. Ingham stands at 175 per 100,000 people, while Detroit is at 800 per 100,000 people.
Last year, county health officials said, 25 people were newly diagnosed with the infection. About 500 people are living with HIV in Ingham County.
Data from the Department of Health and Human Services shows that in the last three years, the use of anti-HIV medications to control or suppress the virus to "undetectable" has grown. In 2012, of people living with HIV in Ingham, Eaton and Clinton counties, 61 percent had undetectable viral loads. In 2013, the number was 65 percent and last year it was 70 percent.
With federal funding, the county's 362 HIV positive clients saw undetectable levels in just over 82 percent of those clients. That's better than the national HIV/AIDS Strategy goal of 80 percent, Ingham County Health Officer Linda Vail said.
"In general we are meeting or exceeding CDC targets," Vail stated. She said that the county was uniquely placed "to be on the front edge" of the goals of the National HIV/AIDS Strategy — which include access to treatment and care for those infected and a reduction in the number of new cases. She credits the Ingham County Community Health Center — a collaboration between a private entity and the county — as well as local partners in this accomplishment.
"I think, absolutely, that when someone tests positive here, there is a benefit in being able to walk them across the hall to a primary care physician and HIV care," she said.
Getting someone into care is key to addressing the disease. But that has been a struggle nationally and locally. Data from the state shows that 608 people are living with the virus in the greater Lansing area, and of those, 431 are considered in care. That's because they have had at least one set of HIV monitoring tests done in the last year. Of those, 362 people are in continuous care, meaning they have had at least two HIV monitoring tests done in the last year. And only 308 of those people are virally suppressed. This is what is known as the treatment cascade and complicates controlling the disease in the community. Those not in continuous care and virally suppressed are more likely to transmit the infection. Those who do not know they are infected are even more likely to transmit the virus. In comparison to other metropolitan areas, Ingham is doing a passable job in overcoming this obstacle.
To get more people into care, the health department will be contracting with the Lansing Area AIDS Network to bring in an early intervention specialist. That specialist will focus on identifying those people who know they have HIV, but are not in care.
That sounds simple enough, but state health officials acknowledged in interviews that the state's strict confidentiality laws related to who can know the names of those infected with HIV could be hampering those efforts. State health officials said they are prohibited from sharing that information with community partners, such as LAAN, by state law, but they are working on a legal work-arounds to address that.
On the prevention side, while the advent of PrEP — a once a day pill to prevent HIV — has been hailed nationally as a "game changer," the reality on the ground has been different. Only one in three primary care physicians and nurses is aware of the intervention, Vail said.
"We need to get our infectious disease doctors out in the community doing grand rounds," Vail said. "They are key to informing other doctors about PrEP. And I think they will be doing that."
Vail reports that ICCHC doctors have prescribed PrEP to "about 50 people."
The combination of Treatment as Prevention (TasP) and PrEP is working in San Francisco. That city saw only 302 new HIV infections last year. A study of 657 men who have sex with men using the drug PrEP as a prevention tool found zero new infections among those men. That model has won praise by national HIV experts. Saenz's use of the medications, which have brought his virus to undetectable levels, is an example of how TasP works.
Dr. Anthony Fauci, the director of the National Institutes of Allergy and Infectious Disease, told the New York Times earlier this year that he "loved" the model.
"If it keeps doing what it is doing, I have a strong feeling that they will be successful at ending the epidemic as we know it. Not every last case — we'll never get there — but the overall epidemic. And then there's no excuse for everyone not doing it," he said.
That model is not without critics however. The study of PrEP use saw half of the participants diagnosed with another sexually transmitted infection — an indication those men were not using condoms. But Vail said that is likely an "artifact" of the PrEP protocol which requires quarterly STI testing.
The San Francisco model may not be fully achievable in Michigan. Treating HIV is expensive — the cost of drugs alone runs tens of thousands of dollars a month. PrEP costs $12,000 a year, or $1,000 a month.
"ACA implementation has expanded insurance options for thousands of People Living With HIV," said Dawn Lukowski, acting manager of HIV care and prevention for the state of Michigan. "However, premiums, deductibles, co-insurances and co-pays can still be prohibitive and present a barrier for low-income PLWH who cannot afford even the reduced costs. Therefore, services like ADAP, health insurance premium and cost-sharing assistance, targeted testing, emergency financial assistance, etc. are all still essential to filling financial gaps left by ACA."
State officials also announced in October they have received a three year grant to develop a pilot project to promote PrEP in Detroit. The first payment for the grant was nearly a half a million dollars. If successful, state health officials believe the lessons learned, and the educational outreach programs developed in Detroit, can and will be rolled out statewide.
For Vail, the county's health officer, the county can do more. While she has only been at the helm for about a year and a half, she said she wants to develop a county wide strategy related to HIV, to bring the various "pockets" of knowledge together.
"I think we can do more as a department," she said. "One strategy has the potential to have a greater impact."
