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HIV Prevention Is the Surest Way to Fight AIDS

ACT UP/NY Demands Department of Health Accountability at the Epicenter of the U.S. Epidemic and Commits to Reinvigorate the National Prevention Agenda

Fall 2013

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Acting Locally, Thinking Nationally

ACT UP's local campaigns on HIV prevention revealed problems and gaps that require data collection and research at the federal level. The bedrock of prevention is HIV testing that's accurate and sensitive to early infection. Undiagnosed MSM, most in early infection, account for 82 percent of new infections, according to a recent study.22,23 The recently approved fourth-generation Alere Determine rapid HIV test detects p24 antigen as well as antibodies to document infection much earlier than previous generations.24 The speedy, universal implementation of this test -- and more sensitive tests in the research pipeline -- will maximize the likelihood of early detection of HIV infection. A recent study using fourth-generation testing reported that 32.4% of HIV infections diagnosed would not have been detected with earlier, less-sensitive testing.23

Fast-tracking research on HIV infection recency- and new-incidence estimation procedures will aid in gathering more complete, accurate numbers. The annual NHBS study, the source of much of what we know about HIV and at-risk populations, would tell us more if the sample size increased. Real-time PCR sampling of NHBS subjects could determine the incidence of acute infection in those who report an unknown serostatus, and their viral load as well, helping to determine the "community viral load." NHBS serosurveys need to ensure that participants who say they are unaware of their infection are not simply reluctant to share personal information. Looking for antiretroviral drugs in the blood of persons of unknown serostatus is one possible way. We also need research into possible correlates of HIV infection in subpopulations at the highest risk for HIV, and studying factors that are behavioral (like differences in sexual networks) and biomedical (like incidence of untreated sexually transmitted infections).

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We need implementation science to support the scale-up of HIV prevention weapons we already have, as well as a robust research and development pipeline for new biomedical interventions. In the age of PrEP, the development of antiretroviral drugs in long-acting formulations for HIV treatment should be accompanied by their parallel development as prophylaxis. We need to increase research into microbicides (rectal as well as vaginal, in multiple modes of delivery)25 and into alternatives to the current condom for barrier protection, including but not restricted to new kinds of condoms. In addition, we need  research to confirm that these alternatives work effectively for anal as well vaginal sex; if they don't, we need to develop alternatives that do.

We need to know more about HIV transmission biology. We need to know to what extent viral suppression translates into lower risk of HIV transmission during anal sex among MSM; only two percent of the serodiscordant couples in the much-cited HPTN 052 study that established the benefits of treatment as prevention were same-sex (male) couples. Easy, available assays to detect the presence of HIV in the semen of virally suppressed patients might eliminate the need for some of that research. To help us evaluate when and for whom PrEP is a good prevention choice, we'll need to monitor for transmission of drug-resistant HIV among patients who've received antiretrovirals prophylactically, and understand the barriers to adherence to PrEP medications in the real world. Will a successful vaccine against HIV be the ultimate prevention technology? Its development will depend on expanding basic and applied research into immune response to HIV.


Prevention as Treatment

More than 1 in 2 young gay men wil be HIV-positive before they are 50 ... unless we act now!

When the Affordable Care Act goes into full effect, the notion of prevention will have statutory standing for the first time. Local and federal agencies must seize the opportunity, coordinate efforts, and mobilize around HIV prevention. We need to fund a full prevention agenda: easy and accurate HIV testing, sex-friendly behavioral programs, prophylactic drugs and a practitioner's network schooled in their use, innovative prevention research, and quick implementation of results -- all within a larger framework of comprehensive primary care that addresses the various health needs of MSM. To spare the current and future generations of men the infection that badly wounded the last one, the HIV cascade of care -- which focuses now on the testing, linkage, retention in care, and treatment of people living with HIV -- will have to extend across the great serodivide and reconceive prevention as treatment, as ongoing care for people who are HIV-negative and at risk, arming them with skills and all the tools available, pharmaceutical and other, to maintain their health.

Design by Bacilio Mendez II, ACT UP/DAWG (the Digital Activism Working Group)


References

  1. Department of State, Office of the Global AIDS Coordinator (U.S.). PEPFAR blueprint: creating an AIDS-free generation. Washington, D.C.: U.S. Department of State Office of the Global AIDS Coordinator; 2012 November. (Accessed 2013 September 26.)
  2. Centers for Disease Control and Prevention (U.S.). Estimated HIV incidence in the United States, 2007-2010. HIV Surveillance Report, 2012. Atlanta: Department of Health and Human Services (U.S.), Centers for Disease Control and Prevention. Vol. 17(4), 2012. (Accessed 2013 September 26.)
  3. Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. Reducing the risk of sexual HIV transmission: Quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use. Sex Transm Dis. 2002 Jan;29(1):38-43. (Accessed 2013 September 26.)
  4. Hensel, D, Rosenberger JG, Novak DS, Reece M. Sexual event-level characteristics of condom use during anal intercourse among HIV-negative men who have sex with men. Sex Transm Dis. 2012 Jul;39(7):550-5. (Accessed 2013 September 26.)
  5. Finlayson, TJ, Teshale E, Jewett A, et al. HIV risk, prevention, and testing behaviors among men who have sex with men -- National HIV Behavioral Surveillance System, 21 U.S. Cities, United States, 2008. MMWR Survell Summ. 2011 Oct 28;60(14):1-34. (Accessed 2013 September 26.)
  6. Rosenberger JG, Reece M, Schick V, et al. Condom use during most recent anal intercourse event among a U.S. sample of men who have sex with men. J Sex Med. 2012 Apr;9(4):1037-47. (Accessed 2013 September 26.)
  7. Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV incidence in men who have sex with men despite high levels of ART-induced viral suppression: analysis of an extensively documented epidemic. PloS One. 2013;8(2):e55312. (Accessed 2013 September 26.)
  8. Vallabhaneni S, Li X, Vittinghoff E, Donnell D, Pilcher CD, Buchbinder SP. Seroadaptive practices: association with HIV acquisition among HIV-negative men who have sex with men. PLoS One. 2012;7(10):e45718. (Accessed 2013 September 26.)
  9. Schmidt AJ, Marcus U, Töppich J, et al. HIV-serosorting among German men who have sex with men. Implications for community prevalence of STIs and HIV-prevention (Abstract 1021). Paper presented at: 19th Conference on Retroviruses and Opportunistic Infections; 2009 February 8-11; Montreal, Québec.
  10. Philip SS, Yu X, Donnell D, Vittinghoff E, Buchbinder S. Serosorting is associated with a decreased risk of HIV seroconversion in the EXPLORE study cohort. PLoS One. 2010 Sep 9;5(9):e12662. (Accessed 2013 September 26.)
  11. Koblin BA, Mayer KH, Eshleman SH, et al. Correlates of HIV acquisition in a cohort of black men who have sex with men in the United States: HIV Prevention Trials Network (HPTN) 061. PLoS One. 2013 Jul 26;8(7):e70413. (Accessed 2013 September 26.)
  12. Koblin BA, Chesney M, Coates T, et al. Effects of a behavioral intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study. Lancet. 2004 Jul 3-9;364(9428):41-50. (Accessed 2013 September 26.)
  13. Padian NS, McCoy SI, Balkus JE, Wassherheit JN. Weighing the gold in the gold standard: challenges in HIV prevention research. AIDS. 2010 Mar 13;24(50:621-35. (Accessed 2013 September 26.)
  14. Centers for Disease Control and Prevention (U.S.). HIV in the United States: the stages of care (fact sheet). Atlanta: Department of Health and Human Services (U.S.), Centers for Disease Control and Prevention. 2012. (Accessed 2013 September 26.)
  15. Stall R, Duran L, Wisniewski SR, et al. Running in place: implications of HIV incidence estimates among urban men who have sex with men in the United States and other industrialized countries. AIDS Behav. 2009 Aug;13(4):615-29. (Accessed 2013 September 26.)
  16. Council of the City of New York. Hearing on the fiscal 2014 preliminary budget & the fiscal 2013 preliminary mayor's management report. Department of Mental Hygiene. New York: Council of the City of New York. 2013 March 7. (Accessed 2013 September 26.)
  17. POZ. NYC concedes cuts to HIV prevention funding. POZ.com [Internet]. February 2012 (cited 2013 September 26).
  18. Osborne D. HIV prevention funds restored, at least for this year. Gay City News. 2012 July 5 (cited 2013 September 26).
  19. New York City Department of Health and Mental Hygiene. HIV/AIDS among men who have sex with men (MSM) in New York City in 2011. HIV Epidemiology and Field Services Program. New York: Department of Health and Mental Hygiene. 2012 February. (Accessed 2013 September 26.)
  20. Eavey JJ, Torian LV, Jablonsky A, et al. Undiagnosed HIV infection in a New York City emergency room. Results of a blinded serosurvey, December 2009 - January 2010 (Abstract TUPE282). Paper presented at: 19th International AIDS Conference; 2012 July 22-27; Washington, D.C. (Accessed 2013 September 26.)
  21. Neaigus A, Reilly K, Jenness S, et al. HIV risk and prevalence among NYC men who have sex with men: results from the 2011 national HIV behavioral surveillance study. 2011. (Accessed 2013 September 26.)
  22. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006 Jun 26;20(10):1447-50. (Accessed 2013 September 26.)
  23. Green K, Moore E, Tomlinson C, et al. Detection of acute HIV infection in two evaluations of a new HIV diagnostic testing algorithm -- United States, 2011-2013. MMWR. 62(24):489-94. (Accessed 2013 September 26.)
  24. Food and Drug Administration (U.S.). FDA approves first rapid diagnostic test to detect both HIV-1 antigen and HIV-1/2 antibodies (press release). (Accessed 2013 September 26.)
  25. Stone A, Harrison P. Microbicides: ways forward. Alliance for Microbicide Development. 2012. (Accessed 2013 September 26.)
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This article was provided by Treatment Action Group. It is a part of the publication TAGline.
 
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