CDC’s Change in HIV Policy Impacted Providers’ Role in Prevention

MedicalResearch.com Interview with:

Rogério M. Pinto, LCSW, Ph.D. Associate Professor Associate Dean for Research School of Social Work University of Michigan Ann Arbor, USA

Dr. Pinto

Rogério M. Pinto, LCSW, Ph.D.
Associate Professor
Associate Dean for Research
School of Social Work
University of Michigan
Ann Arbor, Michigan

MedicalResearch.com: What is the background for this study?

Response: This research, published in Health Education & Behavior (https://doi.org/10.1177/1090198118760681),highlights the crucial role of providers of social and public health services in helping patients to access lifesaving HIV services. Before 2012, providers were encouraged and trained to link patients to behavioral interventions to help patients modify their behaviors to protect themselves against HIV transmission and infection. A shift in policy from targeting anyone at risk to those at highest risk (called “High Impact Prevention”) made these interventions less available (they were actually discontinued) and new policy dictated that providers should have as many people as possible access HIV testing and link them to HIV primary care in order to receive antiretroviral medication.

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HIV Diagnosis and Care Critical To Preventing Spread Of Virus To Others

Jacek Skarbinski, MDMedicalResearch.com Interview With
Jacek Skarbinski, MD

Medical officer
Centers for Disease Control and Prevention

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Skarbinski: Previous research has indicated that HIV diagnosis and viral suppression are important prevention tools that can help reduce continued transmission. However, this analysis is the first to estimate precisely what proportion of transmission can be attributed to individuals engaged in 5 stages of HIV care – including those who are unaware of their infection, those who are retained in care, and those who have their virus under control through treatment.

Our analysis shows that more than 90 percent of new HIV infections in the United States could be averted by diagnosing people living with HIV and ensuring they receive prompt, ongoing care and treatment. It also shows that the further people progress in HIV care, the less likely they are to transmit their virus.

More specifically, the analysis shows that 30 percent of new HIV infections were transmitted from people who did know they were infected, highlighting the importance of getting tested. People who had been diagnosed were less likely to transmit their infection, in part because people who know they have HIV are more likely to take steps to protect their partners from infection.

Finally, the model suggests that simply being in care can help people living with HIV avoid transmission of their virus. According to the model, people who were engaged in ongoing HIV care, but not prescribed antiretroviral treatment, were half as likely (51.8 percent) as those who are diagnosed but not in care to transmit their virus. Being prescribed HIV treatment further lowers the risk that a person will pass the virus to others. People who were successfully keeping the virus under control through treatment were 94 percent less likely than those who did not know they were infected to transmit their virus. But, previous national estimates have indicated that just 30 percent of people with HIV have reached this critical step in care.

In short, this analysis validates the nation’s current prevention efforts, reminding us that HIV diagnosis and care improves the lives of people living with HIV and that it is also critical for reducing the chances of transmitting the virus to others.

MedicalResearch: What should clinicians and patients take away from your report?

Dr. Skarbinski: Both patients and clinicians should know that this is the latest in a growing body of evidence that prevention of new infections depends on reaching people who are HIV-positive with testing, care and treatment.

Once people know they have HIV, they take steps to prevent transmission to their partners. In fact, our study shows a 19 percent drop in the transmission rate after diagnosis – largely because people who found out they had HIV decreased the number of times they had sex without a condom with a negative partner.

After diagnosis, simply being in care can help prevent transmission by giving people living with HIV tools and information they can use to protect themselves and their partners. In addition to treatment, HIV care should include risk reduction counseling, STI screening and treatment, treatment for mental health and substance use disorders, and other prevention services.

The ultimate goal is to provide ongoing care and treatment so all people living with HIV can achieve viral suppression. U.S. guidelines now recommend that everyone diagnosed with HIV should get treatment, regardless of their viral load count. According to our model, people who are virally suppression are 94 percent less likely to transmit their virus than people who are unaware of their infections.

Bottom line: improving the health of people living with HIV is critical for both those with HIV and for those at risk for HIV.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Dr. Skarbinski: The study published today is the just the first in a series. Our next step is to expand the current model and assess the potential impact and costs of different interventions that target different steps of the HIV care continuum. The ability to compare the impact and associated cost of combinations of interventions, such as expanded HIV testing and improved retention in care, on prevention will be critical to guiding public health programs and improve HIV prevention. Moreover, we are also expanding the model to better understand patterns of transmission among particular sub-groups, such as men who have sex with men, to help guide prevention efforts.

You may also view the brief, 60-second video the CDC has put together highlighting the key data from the manuscript and putting them into the context of the nation’s prevention efforts here:  http://www.cdc.gov/nchhstp/newsroom/2015/HIV-Testing-infographic.html?s_cid=nchhstp-hcso-nwsrm-hiv-care-004.

Jacek Skarbinski, Eli Rosenberg, Gabriela Paz-Bailey, H. Irene Hall, Charles E. Rose, Abigail H. Viall, Jennifer L. Fagan, Amy Lansky, Jonathan H. Mermin. Human Immunodeficiency Virus Transmission at Each Step of the Care Continuum in the United States. JAMA Internal Medicine, 2015; DOI: 10.1001/jamainternmed.2014.8180

 

Identifying risky behaviors: The key to HIV prevention

HIV prevention must be better targeted, according to David Holtgrave from Johns Hopkins Bloomberg School of Public Health in the US, and colleagues. Health care professionals need a more detailed analysis and understanding of the interplay between HIV risk behavior, access to treatment and treatment success among those living with HIV. The authors discuss their proposed framework in a study¹ in a special issue of Springer’s journal AIDS and Behavior. The special issue, “Turning the Tide Together: Advances in Behavioral Interventions Research”² is freely available online and will be published in July to coincide with the XIX International AIDS Conference in Washington, DC, from 22 – 27 July 2012.

The National Institutes of Health recently reported a major breakthrough in the fight against HIV. Research showed that treating individuals with HIV with anti-retroviral therapy—so called ‘treatment as prevention’—could reduce the risk of transmission of the virus to healthy heterosexual partners by up to 96 percent. Although these results have been heralded as “the beginning of the end of AIDS,” the research finds that this treatment needs to take a wider perspective and consider the full range of HIV-risk behaviors.

Holtgrave and colleagues’ paper identifies the critical role that HIV-related risk behavior plays in determining the ultimate impact of treatment as prevention. The authors describe the size of the population at risk for HIV and identify three subgroups of people living with the disease. These subgroups include: those who are unaware of their serostatus; those who are aware of their status and do not engage in risky behavior; and those who are aware of their serostatus and are engaging in risky behavior. While all of the subgroups may transmit the virus, they vary considerably in terms of awareness of their serostatus and risk behaviors, as well as the rate at which they could transmit HIV.

For each of these subgroups the researchers identified the most relevant approach: ‘testing and linkage to care’; ‘treatment as prevention’; and/or ‘treatment as clinical care’. They note that the impact ‘treatment as prevention’ might have on the spread of HIV will depend heavily on which subgroup is targeted for this approach.

The authors conclude, “The framework we describe helps us to move more toward ‘complementary prevention’ in which the best interventions from all domains are chosen to address clients’ specific clinical needs and to address public health needs of averting new infections. HIV prevention needs an approach that is truly synergistic, resulting in an effect that is more than the sum of the intervention’s parts.”

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Reference

1. Holtgrave DR et al (2012). Behavioral factors in assessing impact of HIV treatment as prevention. AIDS and Behavior; DOI 10.1007/s10461-012-0186-1. Available at http://dx.doi.org/10.1007/s10461-012-0186-1

2. The special July 2012 issue of AIDS and Behavior “Turning the Tide Together: Advances in Behavioral Interventions Research” is freely available to the general public at http://www.springerlink.com/content/1090-7165/16/5/