It’s hard to see a possible endpoint for the HIV epidemic — it continues spreading each day.
In 2010 (the last available year with a complete data set), the Centers for Disease Control (CDC) reported an estimated 47,500 new infections in America. About two-thirds of those were in gay and bisexual men, with about 11,000 among white males and 10,000 among black ones.
About one in six people living with HIV don’t know they have it, leading the disease to spread further. And the number of new infections doesn’t seem to be changing. As the CDC works on a number of strategies to stem the tide, finally ridding the world of HIV will require newer and more radical ideas.
HIV is a very tricky and evasive virus — our search for a cure has taken lots of time and valuable research money but hasn’t generated many concrete answers. If we want to end HIV, here’s a path that could work:
Mandatory HIV Screening
New infections occur in part because nearly 20 percent of HIV-positive people don’t know they have virus. If every person had to get tested for HIV at least once a year (if not every three months), the number of people unaware of their HIV-status would drop close to zero.
Furthermore, to prevent new infections, everyone with the virus should get treated so that their viral count reaches undetectability. Every tenfold increase in viral load (that is, the amount of virus concentrated in the blood) increases the transmission rate by about two to three times, so reducing viral loads will reduce transmissions as well.
While we can’t force anyone to take a test, physicians and healthcare providers (as well as the government) can increase screenings several ways. Physicians can get the necessary tests completed for their patients at yearly visits while discussing sexual health and other risk factors in a safe, trusting office environment.
The U.S. Preventative Services Task Force — which examines all preventative testing and primary care guidelines — can make stronger recommendations for HIV testing. Insurance companies would have to pay for the testing itself, but such a change would also encourage primary care doctors to urge patients to get tested regularly: “You need to… besides, it’s covered!”
After identifying a person with HIV, treatment is the next step. Most people who know they’re infected have a choice to either delay treatment until their CD4 white cell count is below a target number, or to start treatment immediately. Currently, most doctors prefer to start treatment ASAP after the initial infection to prevent transmission and reduce chronic inflammation from the body reacting to the virus.
But the biggest issue is that once you start treatment, you can never come off the meds, which is a big deal for most folks. Although the side effects of some of these medications have largely improved over the years, effects like fatigue, diarrhea, and headaches still remain. Thankfully we also have once-a-day formulas that minimize these effects, but once you go on a regimen it’s important never to miss a dose. Doing so increases the chances of the virus developing a resistance, forcing you into a more complicated medication regimen.
In this country, treatment options are many and the Affordable Care Act (ACA) has made almost every American living with HIV able to get treatment. HIV medications are insanely expensive — some cost thousands of dollars for just a month’s worth — but all ACA plans have some medications covered with varying co-pays. At the same time, the AIDS Drug Assistance Program (ADAP) helps cover health care and medication costs for those living in or near poverty. Both could help make nationwide treatment possible.
Free and Fully Covered Pre-Exposure Prophylaxis
Multiple studies have now shown that daily use of Pre-Exposure Prophylaxis (PrEP) can reduce the risk of HIV infection by 92 percent. We could significantly blunt the spread of HIV by making PrEP fully available at no cost through full-coverage by insurance or by giving it for free to those without insurance.
Sure PrEP has side effects, but so does any medication, even daily birth control for women. Combined with mandatory HIV screenings, PrEP could reduce new HIV rates to their lowest levels yet. And additional research of more convenient prevention methods — like a once a month shot — have begun showing great promise in animal trials.
The largest hurdle is obviously the money to finance the treatments. Insurance companies can carry some of the burden, and it’s actually in their best interests to do so since treatment for HIV and related illnesses can cost between $250,000 and $420,000 — it’s infinitely cheaper to prevent the disease rather than treat it. All data supports this simple idea.
Lower costs provide a strong motivation for insurance companies to cover new prevention treatments while supporting legislation for improved access and coverage. Plus, the increased demand would spur other pharmaceutical companies to research and develop their own brand of PrEP, increasing competition and number of prevention options while driving treatment costs down even lower.
Dr. Chris Swales is a LGBT family physician working in Northern California, and newly minted blogger writing about healthcare issues for all.
(featured image via Oxfam International)
Previously published March 3, 2015.