2015 Saw Prevention, Treatment Impacts On HIV Epidemic

State health officials earlier this month said they were "cautiously optimistic" that the tools to curb the HIV epidemic were available. That optimism was backed up shortly thereafter with news out of Atlanta. There the CDC reported that from 2005-2014, new HIV diagnoses declined by 19 percent.
That number applies to heterosexuals, people who inject drugs and African-Americans — with the steepest declines among black women. But men who have sex with men — particularly men of color — are not having similar outcomes.
"Among white gay and bisexual men, diagnoses dropped steadily, decreasing 18 percent," the CDC reported in a press release Dec. 6. "Diagnoses among Latino gay and bisexual men continued to rise and were up 24 percent. Diagnoses among black gay and bisexual men also increased (22 percent) between 2005 and 2014, but that increase has leveled off since 2010. A similar trend was seen among young black gay and bisexual men ages 13-24, who experienced a steep 87 percent increase in diagnoses between 2005 and 2014. Between 2010 and 2014, however, the trend has leveled off (with a 2 percent decline)."
"Although we are encouraged by the recent slowing of the epidemic among black gay and bisexual men — especially young men — they continue to face a disproportionately high HIV burden and we must address it," said Dr. Jonathan Mermin, director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. His statement was released Dec. 6 as well. "Much more must be done to reduce new infections and to reverse the increases among Latino men. There is hope that the National HIV/AIDS Strategy and other efforts are beginning to pay off, but we can't rest until we see equal gains for all races and risk groups."
For heterosexuals, intravenous drug users and African-Americans, the decline in new cases has been attributed to successful treatment with anti-HIV drugs. Studies have shown that when a person living with HIV uses the drugs properly to suppress the virus — to what is called an "undetectable level" — it is virtually impossible to transmit the infection. This has been referred to as Treatment as Prevention, or TasP.
State health officials said this year was the first time in years they could report a plateau in new infections.
"The recent five-year trends coincide with the launch of the first National HIV/AIDS Strategy and — now that the investment in high-impact prevention approaches has increased — offer promise for further progress," said Dr. Eugene McCray, director of CDC's Division of HIV/AIDS Prevention. "We have the tools to stop HIV right now. We urgently need to accelerate access to testing, treatment and new biomedical prevention strategies so that everyone can protect themselves and their partners."
While TasP is having an impact in some risk groups, the CDC is also pushing the new prevention intervention of Pre-Exposure Prophylaxis (PrEP). This is the use of the anti-HIV combination pill Truvada. It contains two anti-HIV drugs and when taken daily has been shown to be at least 92 percent effective in preventing an HIV-negative person from contracting the virus. The drug was approved for PrEP in 2012 by the FDA, and in 2014 the CDC released a broad new clinical guidance recommending a significant increase in the prescription of the drug to prevent HIV.
Earlier this month a new report from the CDC recommended that 1 in 4 gay, bisexual or other men who have sex with men take the drug. But the same report found that only 21,000 people nationwide are currently taking the drug — less than 1 percent of the at-risk population. Complicating it, a study found that only 34 percent of physicians and nurses had heard of the intervention.
"We need to get our infectious disease doctors out in the community doing grand rounds," said Linda Vail, Ingham County's Health Officer. "They are key to informing other doctors about PrEP. And I think they will be doing that."
Vail reports that Ingham County Community Health Center doctors have prescribed PrEP to "about 50 people."
The combination of Treatment as Prevention 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.
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 (PLWH)," 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 premiums 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.