New England AIDS Education and Training Center: ContentPages

In Brief: January 10, 2020

Inside This Issue: Highest-ever viral suppression rates in Ryan White clients; HIV comorbidities; treatment as prevention; HIV, intimate partner violence, and women; drug pricing and access; updates to HIV treatment and opportunistic infection guidelines; and educational resources.

The HIV Continuum of Care

Viral Suppression Rate for RWHAP Clients Reaches Highest Level Ever

In 2018, 87.1% of clients receiving medical care through the Ryan White HIV/AIDS Program (RWHAP) achieved viral suppression – a record high level, according to the 2018 RWHAP Annual Client-Level Data Report released last month. Each year, the report summarizes data reported by more than 2,000 funded RWHAP grant recipients and subrecipients across the U.S. The publication, produced by the Health Resources and Services Administration (HRSA), provides detailed demographic information about clients receiving RWHAP services and highlights progress and disparities in HIV-related outcomes, including retention-in-care and viral suppression rates. Client-level data is also analyzed by age, race/ethnicity, transmission risk category, federal poverty level, health care coverage, and housing status.

Several key findings from the latest report are summarized below and in an accompanying infographic. Unless otherwise stated, the highlights below are for the year 2018.

A total of 533,758 clients were served in the RWHAP – more than 50% of all people living with diagnosed HIV in the U.S.;
Among RWHAP clients receiving medical care, viral suppression rates rose from 69.5% in 2010 to 81.4% in 2014, and 87.1% in 2018;
However, during the period from 2014 through 2018, the retention-in-care rates for RWHAP clients have remained relatively steady – in the range of about 80% to 82%;
Nearly three-quarters (73.7%) of RWHAP clients were racial/ethnic minorities, including 47.1% who identified as Black/African American, and 23.2% who identified as Hispanic/Latino;
Nearly half (46.1%) of RWHAP clients were aged 50 or older; and
Most clients (61.3%) had incomes at or below 100% of the Federal Poverty Level.

Living with HIV

NIAID: Efforts to End the HIV Epidemic Must Address Comorbidities in Persons Living with HIV

“To effectively solve the global health crisis HIV represents, the comorbidities among persons currently living with HIV must be addressed simultaneously with collective efforts to end the epidemic of new HIV transmissions,” according to a recent JAMA editorial by Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), and his colleagues. Even if the U.S. goal of reducing HIV transmission 90% in 10 years is achieved, there will still be at least one million people living with HIV (PLWH), and their medical needs – including comorbidities – must be addressed. PLWH have a disproportionately high risk of cardiovascular disease, chronic kidney disease, osteopenia, osteoporosis, liver disease, and cancer, according to the editorial. They may also develop some health conditions at younger ages than persons without HIV.

“Since the early years of the HIV epidemic, much has been accomplished, mainly due to the advent of ART [antiretroviral therapy],” Fauci and colleagues note. “However, much remains to be done in the identification, mitigation, and treatment of HIV-associated comorbidities that continue to be a challenge even in the era of ART. Additional research on the underlying pathogenesis of these conditions, randomized clinical trials to assess treatments, and a reduction in health care disparities must be prioritized moving forward. HIV-associated comorbidities also represent a significant economic challenge that must be addressed.”

Treatment as Prevention

Many Gay and Bisexual Men Agree that HIV “Undetectable Equals Untransmittable,” But Misunderstandings Persist

An extensive body of research has firmly established that people living with HIV who achieve and maintain an undetectable viral load (VL) by taking ART as prescribed do not sexually transmit HIV to others. This approach of HIV treatment as prevention (TasP) is summed up in the phrase “Undetectable Equals Untransmittable,” or “U=U” for short. Despite the overwhelming evidence concerning the efficacy of TasP and efforts of public health and HIV advocacy groups to promote the U=U message, the science of HIV viral suppression and transmission risk has not been well understood by the general public and key groups living with HIV.

To shed light on public acceptance and understanding of the U=U message, researchers from the City University of New York (CUNY) conducted an online cross-sectional survey from November, 2017 through September, 2018 to gather data from a total of nearly 112,000 men who have sex with men (MSM) in the U.S. The CUNY researchers found that, overall, 54% of HIV-negative survey participants and 84% of participants with HIV correctly identified the U=U message as accurate. However, among participants who did not know their HIV status, less than half – 39% – believed the U=U message was accurate.

Even among men who agreed that the U=U message is “completely accurate,” only 31% believed transmission risk is zero when the insertive partner’s VL is undetectable, and only 39% felt the risk was zero when the receptive partner’s VL is undetectable. However, acceptance of U=U was associated with lower perceived risk of HIV transmission through any form of condom-less anal sex.

“A growing number of sexual minority men believe that U=U is accurate, but our data suggest that most still overestimate the risk of HIV transmission from an undetectable partner, which may be because people have trouble understanding the concept of risk,” noted Jonathon Rendina, the lead author on the study. “All published studies point to undetectable viral load as being the most effective method to date of preventing sexual HIV transmission, but most of our messaging has focused on the level of risk being zero rather than describing it in terms of effectiveness, which is the way we usually talk about condoms and PrEP.”

Women and HIV

Kaiser Brief Examines HIV, Intimate Partner Violence, and Women

Women living with or at risk for HIV infection are disproportionately affected by intimate partner violence (IPV), which includes physical violence, sexual violence, or stalking by an intimate partner. Researchers have found that women who have experienced IPV are at increased risk for HIV, and that IPV is associated with poorer treatment outcomes among women living with HIV. In consideration of the role that IPV plays in HIV risk, transmission, care, and treatment, the Kaiser Family Foundation (KFF) recently published an issue brief highlighting key statistics about IPV, the links between HIV and IPV, and policy initiatives and changes that address these challenges.

At some time in their lifetime, about one-third (36%) of all U.S. women have experienced intimate partner violence (IPV), Among women living with HIV, the rates of IPV are even higher – 55%. Compared to women in nonviolent relationships, women who have experienced IPV have a four times greater risk of contracting sexually transmitted infections, including HIV. A nationally representative study found that one in five women (20%) living with HIV had experienced violence by a partner or someone important to them since their diagnosis. Among these women, half believed that the violence was directly related to their HIV serostatus.

The Affordable Care Act (ACA), which was signed into law in 2010, has several provisions that protect persons who have experienced IPV, including those living with HIV. These ACA provisions:

eliminate pre-existing condition exclusions and premium rate setting based on health status, such as HIV infection or being a survivor of IPV;
include no-cost coverage of preventive services for women, including IPV screening and counseling;
extend insurance enrollment periods for survivors of IPV;
establish maternal and child visitation programs focusing on domestic violence; and
establish a Federal grant program with funding for states’ and tribal organizations’ support services for pregnant teens and women, including those experiencing IPV.

The brief also summarizes several other ongoing or planned initiatives that address the intersection of HIV and IPV. “Addressing trauma and violence experienced by women with and at risk for HIV aims to provide care and support in the immediate term, but in the longer term, may also be an important contribution in combating the HIV epidemic,” according to the brief. “Key policy changes, including those ushered in by the ACA and other opportunities outlined above, provide important vehicles for targeted interventions to address IPV in HIV-positive and at-risk women.”

Access to Treatment

NASTAD Releases Drug Pricing and Access Principles to Help Address Health Disparities

NASTAD recently released a set of principles for drug pricing and access to support its mission to end the HIV and hepatitis epidemics. “Treatment and biomedical prevention advances – and the innovative research and development behind them – have revolutionized our ability to provide lifesaving interventions to millions of people living with, or at risk for, HIV, hepatitis C virus (HCV), and substance use disorders worldwide,” according to NASTAD. “Yet access to these prevention, treatment, and curative medications in the United States has been inefficient, expensive, and profoundly inequitable.” NASTAD’s drug pricing and accessing principles are designed, in part, “to help address the health disparities that have fueled disproportionate access to healthcare in the United States.”

NASTAD’s nine drug pricing and access principles include recommendations to:

rein in drug list prices – including launch prices and price increases on existing products – to increase and sustain access to medication;
accelerate the development of generic, quasi-generic, and lower-cost brand-name medications that can compete with, and provide alternatives to, more expensive drugs.
base public and private insurance formularies on evidence-based clinical standards of care;
reform cost-sharing practices, including commercial market copayment and coinsurance structures, to ensure access to medications;
balance clinical, ethical, and sustainability considerations when ensuring access to medications;
evaluate the extent to which drug rebates secured by pharmacy benefits managers in the commercial market actually benefit consumers;
ensure that the pricing of drugs and biologic products reflect manufacturer, government, and philanthropic investments in research and development;
recognize the key role of the Federal 340B Drug Pricing Program in ensuring that low-income, vulnerable populations have secure access to HIV, hepatitis, and overdose medications; and
address what NASTAD views as the current overreliance on charitable medication access programs, and develop sustainable public health systems built on a range of funding mechanisms to ensure access to drugs.

Guidelines

HHS Expert Panels Update HIV Treatment and Opportunistic Infection Guidelines

Last month, the expert panels responsible for developing the Department of Health and Human Service (HHS) guidelines for HIV treatment and the management of opportunistic infections (OIs) updated three of their guidance documents. The Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV have been extensively updated. The revisions include new guidance regarding:

use of ART to prevent sexual transmission of HIV (treatment as prevention);
recommended treatment options for persons starting ART, and when to start;
specific options for persons with acute or recent HIV infection;
cost considerations that can affect patients’ access to ART;
use of the drug dolutegravir in women of childbearing age;
lab testing and monitoring for PLWH who are receiving ART; and
treatment of tuberculosis (TB) in persons with TB/HIV coinfection.

The HHS Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States have also been updated with revised guidance on:

patient counseling and informed decision-making on HIV treatment options for women who are pregnant or trying to conceive, including regimens containing dolutegravir;
reproductive options for couples in which one or both partners are living with HIV;
the use of antiretroviral drugs during pregnancy, including for women receiving ART who become pregnant and for pregnant women who have never received ART; and
special considerations for women receiving ART who have not achieved viral suppression, and those with acute HIV infection, HIV-2 infection, or coinfection with hepatitis B or hepatitis C.

Finally, the Varicella-Zoster Virus (VZV) section of the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children has been updated to include new information about VariZIG, a drug used for post-exposure prophylaxis of VZV infection in persons exposed to that virus.

Educational Resources

Current AJPH Issue Focuses on Efforts to End the U.S. HIV Epidemic

The January issue of the American Journal of Public Health (AJPH) includes several research articles and opinion pieces that describe in detail the Trump Administration’s proposed initiative, Ending the HIV Epidemic: A Plan for America. The issue also features research on HIV trends in multiple geographic regions, patterns of HIV transmission, and best strategies for HIV treatment and prevention. For your convenience, we have provided links to the full text or abstracts of selected articles and opinion pieces below: