Key Facts
36.9 million living with HIV; 1.8 million infected and 940,000 deaths annually (2017).
1.1 million living with HIV; 40,000 new diagnoses and 15,000 deaths annually (2016).
altogether from the beginning of the epidemic.
In February 2019, President Trump announced an “End the HIV Epidemic” initiative to reduce new HIV infections by 75 percent in five years and by 90 percent in 10 years. In his budget for the first year of this initiative, Trump proposed $291 million toward this effort.
In February 2019, President Trump announced an “End the HIV Epidemic” initiative to reduce new HIV infections by 75 percent in five years and by 90 percent in 10 years. In his budget for the first year of this initiative, Trump proposed $291 million toward this effort.
The effort will initially be concentrated in 48 counties, DC, San Juan, Puerto Rico, and 7 states with rural epidemics—all areas with significant incidence. The initiative involves multiple agencies and organizations including the Centers for Disease Control and Prevention, Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration, the Indian Health Service and the National Institutes of Health, and includes funding for the Centers for AIDS Research like the one at Emory.
Although the first cases of HIV/AIDS were diagnosed in California and New York, the epicenter of the U.S. epidemic is in now the South where 52 percent of new diagnoses occur. Georgia has the highest number of new diagnoses of any state and Atlanta ranks number two among metropolitan statistical areas (MSA) for new diagnoses. Nine of the top 10 MSAs in new diagnoses are in the South. African-Americans are disproportionately affected by HIV. The lifetime estimated risk of a black MSM (men who have sex with men) acquiring HIV in their lifetime is 1 in 2.
Undetectable = Untransmittable: The goal of therapy is now not only to improve the health of those living with HIV (who with appropriate therapy can achieve a near normal life span) but also to prevent transmission to others. About 80 percent of new U.S. HIV infections are transmitted by the 40 percent of those with HIV who are not aware they are infected or are not receiving care. Only around 50 percent of those with HIV have achieved viral suppression in the U.S., which is substantially worse than many countries both in the developed world (the United Kingdom, for example) and in the developing world (Botswana, for example).
Strategies to Reduce New Infections:
The two most effective strategies available to reduce new infections are:
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Treatment as Prevention: Those who are living with HIV and are in continuous care with viral suppression have zero risk of transmitting the virus to others. Strategies to ensure that those living with HIV are diagnosed, linked, and retained in continuous care have promise. In each one of those steps—diagnosis, linkage to care, retention in care and antiretroviral initiation and adherence—there are important challenges.
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Retention in continuous care is a particular challenge. Barriers include stigma (and policies that increase stigma including HIV criminalization), structural racism, medication access (worse in states without Medicaid expansion), policies that restrict health care for LGBTQ individuals, medical mistrust, transportation, food insecurity, poverty and other social determinants of health, incomplete access to mental health care, and incomplete access to addiction and substance abuse care among other factors.
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With the burgeoning opiate epidemic, there is enhanced risk of expanded HIV transmission through injection drug use; syringe services programs and expanded access to addiction treatment including medication-assisted therapy are critical.
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PreExposure Prophylaxis (PrEP): The use of a daily pill (Truvada®) to reduce risk of infection, has been very effective but reaches a small minority of individuals at risk who would benefit from it. Access and education about PrEP are two important factors. While Gilead Sciences has pledged to donate enough Truvada® to treat 200,000 low-income patients for up to 11 years, this effort falls far short of the number of individuals at risk who need PrEP. Currently the cost of the drug is prohibitive and far greater in the U.S. than in other developed countries. For example in the U.S., Truvada® costs approximately $2,000/month while in France, the similar treatment costs $10/month. Efforts to make PrEP widely available and affordable are critical. In addition, in states like Georgia without Medicaid expansion, even with free Truvada®, the cost of care needed to prescribe it will be prohibitive.
Together, prevention as treatment and PrEP are two strategies that have been shown to be effective in dramatically reducing incidence in many countries. The U.S. is far behind.
Prevention Research
PrEP or the use of antiretroviral medications taken before exposure to prevent new HIV infection: In addition to daily oral pills, other types of antiretroviral prevention strategies are being investigated including broadly neutralizing antibodies, long-acting injectable PrEP, intravaginal polymer rings, oral use with schedules that range longer than daily, and implants. Emory is a site of the NIH/NIAID-funded HIV Prevention Trials Network (HPTN), and we have enrolled participants in a study looking at a broadly neutralizing antibody (HPTN 085) and a long-acting injectable (HPTN 083).
Vaccines: Development of a safe and effective vaccine remains an essential part of the strategy for ending HIV. There remain many challenges to a safe and highly effective vaccine but significant laboratory-based research and clinical trials are in progress. Strategies include the search for a vaccine to prevent infection (the traditional model) and vaccines to provide a “functional cure,” defined as strengthening the recipient’s immune system to control the virus without medications even if infection occurs.
Some of these strategies include developing broadly neutralizing antibodies—either as injections or using other means to coax an individual into developing a specific immune response to control virus.
Emory has been a leader in HIV vaccine research and a vaccine developed here by Dr. Harriet Robinson is now in clinical trials. Emory is also a site for the NIH/NIAID-funded HIV Vaccine Trials Network (HVTN).
To date HIV vaccine trails have been disappointing but trials with a new generation of HIV vaccines are now underway.
Research in Treatment
Long-acting injectable antiretroviral therapy (monthly injections) has been broadly studied and is likely to be approved soon. This would allow those living with HIV to not have to take daily pills and many in these treatment trials have found this to be favorable. Use of this strategy for patients who have trouble taking daily pills is under investigation through the NIH/NIAID-funded AIDS Clinical Trials Network (ACTG). Emory is a site of the ACTG and will be enrolling for this study.
Ongoing studies evaluating strategies to retain more vulnerable, hard-to-reach patients in care (who have many barriers to care) are underway. Emory investigators have been leaders in developing and testing strategies to link and retain persons living with HIV in care.
Cure Research
Bone marrow transplants: Despite media attention to bone marrow transplant as a route to cure, only two or three individuals have benefited from this therapy (each with concurrent cancer) and the risk of mortality with a bone marrow transplant far exceeds the risk of mortality with current standard of care antiretroviral therapy (ART). This is not a strategy that will ever be widely used or available but provides important opportunities to refine other strategies that may be broadly applicable.
Latency reversing agents: Activating the hidden HIV reservoir could enhance the ability of ART to kill the virus.
There are many ongoing studies looking for a cure for HIV, and Emory investigators are actively involved in HIV cure research.