Over the past decade, the District of Columbia has seen more than a 74% decrease in the number of new HIV infections, from 1,333 new cases in 2007 to 347 in 2016. Although a myriad of public health programs have contributed to this decline, the most impactful has been treatment as prevention, according to Michael Kharfen, senior deputy director of HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA), D.C. Department of Health.
Since 2007, the District has launched a number of campaigns, including on needle exchange, condom distribution and, more recently, pre-exposure prophylaxis (PrEP). Yet, the "leading driver in reducing new transmissions" has been treatment as prevention, or ensuring that HIV-positive people become aware of their status and start daily antiretroviral treatment, said Kharfen.
A growing body of research has demonstrated that people with HIV who take their medication every day can reduce the level of virus in their blood to an undetectable level, meaning they cannot transmit the virus to others through sex, needle sharing or from mother to child.
The enormous impact of this strategy is the reason Washington, D.C., now supports the Undetectable = Untransmittable, or U=U, campaign. Launched in early 2016 by the Prevention Access Campaign, U=U is a nationwide effort to spread the word about the effectiveness of treatment as prevention.
In June 2017, the District of Columbia's mayor, Muriel Bowser, announced that the District would launch its own U=U campaign, joining New York City. The campaign will cost somewhere between $50,000 to $60,000 this year, and will include bus signs and digital education materials, according to Kharfen, who described the U=U message as empowering for people with HIV.
"For the first time [since] HIV has been around, we are not saying negative things about people with HIV," said Kharfen. "When people living with HIV take their medication, they are now being the leading contributors to us ending the HIV epidemic."
In addition to treatment-as-prevention strategies, a number of new prevention efforts have contributed to the steep drop in new HIV infections in Washington, D.C. Some of these efforts were inspired by the results of a 2007 cohort study finding that almost 50% of study participants with HIV living in the District were not aware of their status, said Kharfen.
At the time, the Centers for Disease Control and Prevention (CDC) estimated that approximately 21% of people with HIV were unaware of their status, indicating that Washington D.C. likely had a much higher rate of undiagnosed people than the national average, Kharfen explained. That study led to an effort to expand HIV testing, which led to a sharp rise in newly diagnosed people in 2007 and 2008.
In addition, for nearly 10 years, Washington, D.C., had been prohibited from using any public funds on needle exchange programs, but in 2007, Congress lifted the ban, paving the way for the District to scale up its needle exchange services.
The results have been dramatic. In 2007, the District counted 147 new diagnoses from injection drug use, which accounted for approximately 15% of all new diagnosis. By 2016, that number had dropped to seven, or only 2% of all new diagnosis.
"We attribute that [drop] to our ability to have syringe services available," said Kharfen.
Another important factor in the drop in new infections has been the scale-up of condoms. Although this prevention method is more difficult to quantify, Kharfen is a strong believer in the power of condoms as a prevention method. In 2007, the public health department introduced a citywide condom distribution program.
"When we started this, I said my goal was to create a river of latex," he said. In 2007, the program distributed 500,000 condoms. By 2016, it scaled up to six million condoms.
PrEP, which was officially endorsed by the CDC as an effective prevention strategy in 2014, "is almost more forward-thinking for us at this point," said Kharfen. The District's public health department has become, after New York, the second major U.S. city to start advertising PrEP directly to black heterosexual women, a group that has a high prevalence of HIV yet is often overlooked as a potential target population for PrEP.
Although there are other demographic shifts, such as the gentrification of the D.C. metro area, that may have contributed to the decline in new HIV cases in the last 10 years, Kharfen notes that the District's ability to ramp up services since 2007 has played a vital role.
Now, he and his colleagues want to focus on tailoring the U=U campaign to the right communities, and will include representations of black gay, bisexual and non-gay identified men in the campaign's promotional materials.
"We're going to work with our community about how to get this message across [that] getting people on treatment not only improves their health, but also population health," he said.