Major Gaps in Access to Care Are Impeding Progress in Reducing HIV/AIDS
HIV Specialists Meet to Identify Unmet Needs of Those at Greatest Risk
August 13, 2012
Washington, D.C. -- As global leaders assembled in Washington for the XIX International AIDS Conference, a special gathering of researchers, government officials and HIV/AIDS advocates confronted the new reality of the epidemic in the U.S. -- a dramatic increase in HIV among men who have sex with men (MSM), minority populations, the poor and the disenfranchised living in discreet geographic regions, especially in urban areas of the Northeast and West Coast and cities and small towns in the South.
Taking part in a policy round table convened by the Forum for Collaborative HIV Research, those on the front lines in delivering HIV care presented a disturbing picture of the new "face" of HIV/AIDS in America, where the prevalence of HIV infection in some high-risk populations rivals that of parts of sub-Saharan Africa. Among MSM alone, the prevalence of HIV is as high as 30%, which is much greater than a general-population prevalence of 7.8% in Kenya and 16.9% in South Africa. Moreover, in large cities, certain subpopulations are especially hard hit. In New York City, 1 in 40 blacks, 1 in 10 MSM and 1 in 8 injection-drug users are HIV-infected, as are 1 in 16 black men in Washington, D.C.
"Even as the world focuses on sub-Saharan Africa, where approximately two thirds of the world's HIV/AIDS population resides, we cannot overlook the persistent challenge of HIV prevalence in the United States and especially, the unequal burden on Americans with HIV who live in poverty, face terrible stigma and are falling through the cracks of the healthcare system," said Veronica Miller, Ph.D., Director of the Forum. "Despite great strides made over the last three decades in the care and treatment of people living with HIV, there is an urgent need for an expanded investment in routine HIV testing and in community-based programs that will link newly diagnosed patients to care and keep them in treatment."
Updated ART Guidelines Established Need to Treat Everyone with HIVLaying the groundwork for the roundtable discussion, John G. Bartlett, MD, Professor of Medicine in the Division of Infectious Diseases at The Johns Hopkins University School of Medicine and co-chair of the Forum's Executive Committee, summarized the changing science on HIV transmission since 2009 which resulted in the Department of Health and Human Services (HHS) issuing new treatment guidelines that call for accelerating the use of antiretroviral therapy (ART) in everyone diagnosed with HIV. Moreover, the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents, which Dr. Bartlett chairs, also calls for the use of ART to prevent transmission of HIV from an infected individual to a sexual partner, a strategy known as treatment as prevention.
"The 2012 guidelines mark an important milestone in the treatment of HIV. After years of debate on when to initiate antiretroviral therapy, there is now scientific consensus that ART is an important strategy for reducing HIV transmission and should be made available to everyone, regardless of their CD4 count," said Dr. Bartlett. "Based on what we know today, it can be argued that all patients diagnosed with HIV infection are candidates for ART."
Serious Gaps in Access to HIV Care Are Impeding ProgressEven as the new HIV treatment guidelines call for all people with HIV to receive antiretroviral therapy, Dr. Kenneth H. Mayer, MD, Director of HIV Prevention at Beth Israel Deaconess Hospital and the Medical Research Director of The Fenway Institute in Boston, cautioned that significant gaps in access to HIV care are limiting the potential of ART. According to the latest estimates, of the 1.2 million Americans who now live with HIV, more than 200,000 don't know they are infected and as many as 850,000 that received an HIV diagnosis (72%) don't have the virus under control.
What is behind these statistics, according to Dr. Mayer, are significant shifts in the demographics of HIV/AIDS in the U.S., which is now concentrated among MSM, ethnic minorities and low-income Americans. Describing the evolving face of HIV/AIDS in the U.S., Dr. Mayer said African Americans bear the greatest burden of the disease and Hispanics are also disproportionately affected. Based on 2009 data, blacks now represent 44% (21,200 cases) of all new infections in 2009, including 31% of new infections in men and 57% of new infections in women. Hispanics, which represent approximately 16% of the total U.S. population, accounted for 20% (9,400) of all new HIV infections in 2009.
Among MSM, there has been a dramatic rise in infection rates among young gay and bisexual men ages 13-29 years, who today collectively represent more than one quarter of all new HIV infections nationally (27% or 12,900 in 2009). Of the young MSM population, new HIV infections increased 48% over a four-year time period -- from 4,400 HIV infections in 2006 to 6,500 infections in 2009. According to new studies on this patient population, MSM are regularly excluded from HIV services because of stigma and discrimination, which puts them at higher risk for depression, substance abuse and intimate partner violence.
Black MSM also have high rates of undiagnosed HIV and sexually transmitted infections, which were associated with such factors as poverty, unemployment, their local neighborhoods and having unprotected sex. In one recent study, 12% of the 1,379 men recruited from six high prevalence cities tested positive for HIV on entry to the study. HIV incidence was especially high among young black MSM, those reporting unprotected receptive anal intercourse, and those with sexually transmitted infections (STI's) when the study commenced.
Along with the new demographics of HIV/AIDS, Dr. Mayer said the U.S. epidemic is concentrated in specific neighborhoods around the country -- the urban areas of the Northeast and West Coast and in the South -- and especially in underserved areas known as HIV "hot spots" where transmission rates are as high as the most HIV-infected areas of sub-Saharan Africa. Citing new evidence from the ISIS study (The Women's HIV Seroincidence Study), Dr. Mayer said black women living in six HIV "hot spots" have a five-fold higher incidence rate of HIV than the overall rate of infection among black women estimated by the Centers for Disease Control and Prevention (CDC). Besides living in poor and disenfranchised neighborhoods, the ISIS study attributed these higher rates of HIV in at-risk women to substance abuse, food insecurity, and contact with partners who either did not know or did not disclose their HIV status. The six cities where the hot spots are located are Atlanta, Baltimore, Newark, New York City, Raleigh-Durham, and Washington, DC.
"What this data clearly indicates is that the HIV epidemic today is concentrated among the disenfranchised and socially marginalized living in underserved communities," said Dr. Mayer. "If we are to reverse the tide of this epidemic, we must focus on the root causes of HIV disparities in at-risk communities, including stigma, poverty, STC prevalence, incarceration, and limited social mobility."
New Approaches to Linkage to Care and RetentionReacting to the latest CDC projections that only 69% of people diagnosed with HIV currently receive care and fewer than a third (28%) achieve complete viral suppression with treatment, a roundtable of experts addressed the challenges to improving the continuity of treatment for HIV, agreeing that declining federal and state budgets for HIV programs, a fragmented healthcare system and the lack of familiarity among clinicians and community health centers about existing testing and treatment programs are the major barriers to progress. Moreover, the panel identified the major reasons people with HIV are not linked to care, citing lack of insurance, substance abuse and mental health problems, health literacy, stigma and lack of "readiness" where people with diagnosed HIV delay their entry into care due to fear and/or difficulties with transportation, time off from work and family obligations.
To overcome these barriers, the panel focused on the need for innovative thinking at the community level that will lead to new approaches to expand routine testing and link newly diagnosed patients into care as soon as possible. Focusing on what is already working at the local level, the panel cited a range of innovative community-based approaches, such as social networking, which enlists HIV-positive and high-risk HIV negative persons in communities of color to identify and recruit high risk individuals from their social, sexual, or drug-using networks. Other successful strategies include the use of health system navigators in HIV clinics, mobile street vans that deliver medical and supportive services to HIV patients in inner city neighborhoods, and transitional care management to retain ex-offenders in care.
"Ultimately, HIV care is local, which means that communities and the states will drive innovation in linkage and retention in care programs," said Dr. Miller.
Held in Washington On July 25, the meeting -- Closing the Gaps in Access to HIV Care: A Round Table on Emerging Approaches to Linkage and Retention -- featured a moderated discussion among the following HIV/AIDS leaders: Bruce Agins, MD, MPH, Medical Director of the New York State Department of Health's AIDS Institute; A. Cornelius Baker, Project Director of the FHI 360 Center on AIDS & Community Health (COACH) in Washington, DC; Sally Hodder, MD, Director of the HIV/AIDS Program at the New Jersey School of Medicine; Aaron Lopata, MD, with the White House Office of National AIDS Policy; RADM Deborah Parham-Hopson, PhD, RN, FAAN, Associate Administrator of the HIV/AIDS Bureau within the Health Resources and Services Administration (HRSA); and Jonathan Mermin, MD, MPH, Director of the CDC's HIV/AIDS Prevention Program.
The symposium also introduced a novel online training tool for healthcare providers, Bridge 2 Care, that assists in developing provider skills and knowledge around HIV testing and engagement in care. For additional information, including sponsorship of the project, please visit www.hivforum.org.
This article was provided by Forum for Collaborative HIV Research.
Add Your Comment:
(Please note: Your name and comment will be public, and may even show up in
Internet search results. Be careful when providing personal information! Before
adding your comment, please read TheBody.com's Comment Policy.)