contact with care services for those who are diagnosed, is as significant as targeting risky sexual and drug use behaviors for cutting the total estimated number of 45,000 HIV transmissions every year in the US, found the authors of research published today.
The study, in JAMA Internal Medicine, concludes that
improving the health care reach, "primarily" to those HIV-
infected people who are undiagnosed and not receiving
antiretroviral therapy, "would have a substantial effect on HIV
transmission in the United States."
Dr. Jacek Skarbinski, of the US Centers for Disease Control and Prevention (CDC) in Atlanta, GA, and colleagues estimated the rate and number of HIV transmissions that could be attributed to each of 5 steps in the "care continuum" for patients.
The researchers used national databases for 2009 estimates,
finding that in the US that year, more than 1.1 million people were living with HIV. Of those:
1. The infected but undiagnosed people amounted to
207,600 (18.1%)
2. Diagnosed but not in medical care - 519,414 (45.2%)
3. Retained in medical care but not prescribed antiretroviral
therapy (ART) - 47,453 (4.1%)
4. Prescribed ART but not virally suppressed - 82,809
(7.2%)
5. Achieved viral suppression - 290,924 (25.3%).
The definition used in the study for "retention in care" for
people diagnosed with HIV infection was that they had
completed "at least 1 visit with an HIV care provider during a
single 4-month period in 1 calendar year."
The authors conclude: "In the United States, persons living
with HIV who are retained in medical care and have achieved
viral suppression are 94% less likely to transmit HIV than
HIV-infected undiagnosed persons."
The authors add: "Improvements are needed at each step of the
continuum to reduce HIV transmission."
The study concludes that goals to increase the number of
people with HIV who know their status, get health care, and
receive and adhere to ART, could be realized by the US with
"meaningful gains" through "stronger coordination of efforts" among individuals, HIV care providers, health departments, government agencies.
The research found that those people infected with HIV but undiagnosed, plus those diagnosed with HIV but not in medical care, made up almost 92% of the estimated 45,000 transmissions in 2009 (61% were accounted for by the latter group not in contact with care services).
In addition to the 94% reduction in transmission achieved by full care, achieving the other care steps also reduced rates, the
results of the study show.
Those people who were diagnosed but not retained in medical
care, for example, were 19% less likely to transmit HIV than
those who remained undiagnosed.
Stratifying risk of HIV transmission by sex, acquisition risk category and age group, the authors found that the following
groups accounted for most transmissions:
Men
HIV acquisition via male-to-male sexual contact
Age 35 to 44 years.
Viral load decreases as 'care cascade' progresses
A commentary article accompanying the study - written by a researcher who found in 2005 that just a quarter of HIV-
infected people in the US were estimated to have achieved viral
suppression - says that the current findings turn the "treatment cascade into an HIV prevention tool."
"The results," says Dr. Thomas Giordano, "confirm what is
apparent from a careful consideration of the cascade: as the cascade proceeds from undiagnosed HIV to viral suppression, the average viral load decreases, and there is a glut of persons lost in the cascade between diagnosis and retention in care."
Delayed diagnosis and inadequate retention in care are - "not surprisingly" - the steps of the cascade that "propel HIV transmission in the United States," Dr. Giordano concludes.
Dr. Giordano asks what can be done about the problem, and
proposes more HIV testing among the solutions. (The CDC
recommends universal screening of all adults and adolescents in routine health care settings, but "local practice and many
Medicaid reimbursement policies are not consistent" with this.)
Dr. Giordano says: Even simple customer care approaches could improve HIV- infected people's retention in medical care programs, says Dr. Giordano: "Care should be efficient, courteous, patient-oriented
and delivered in a welcoming environment."
In other HIV news, last week, a new, aggressive form of the
virus was identified in Cuba. If undiagnosed HIV infection
remains a challenge in the US, it is more so in developing
countries, but a smartphone accessory has been developed that " diagnoses HIV and syphilis in 15 minutes."
Finally in other news last week, a novel drug candidate against HIV has been created.
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