Can we end the HIV epidemic in a decade?

Patrick Sullivan and PRISM Health researchers created AIDSVu, the first interactive map to break down the HIV/AIDS epidemic in the United States by state, county, and metropolitan area. Of the top 25 metros in terms of HIV prevalence, 21 are south of the Ohio River.

Key Facts

Global:
36.9 million living with HIV; 1.8 million infected and 940,000 deaths annually (2017).
U.S.:
1.1 million living with HIV; 40,000 new diagnoses and 15,000 deaths annually (2016).
35 million deaths
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:

  1. 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.

    1. 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.

    2. 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.

  2. 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.

CDC HIV Surveillance Report

HIV Surveillance Report

38,739 Total HIV Diagnoses in 2017

HIV Diagnoses Trends from 2012–2016

  • Women: down 9%
  • White PWID (People who inject drugs): up 25% (Decreasing among PWID in all other races/ethnicities)
  • MSM (Men who have sex with men) overall: stable
  • 25–34 year olds: up 13%

Trends in MSM Diagnoses from 2012–2016 by Race/Ethnicity

  • Whites: down 14%
  • Hispanics/Latinos: up 12%
  • Blacks/African Americans: stable
  • Asians: up 26%
  • AI/AN (American Indians/Alaskan Natives): up 58%
MSM diagnoses in 25–34 year olds increased by:
  • +22% in Hispanics/Latinos
  • +34% in in Blacks/African Americans

Diagnoses by Race/Ethnicity

In 2017, Blacks/African Americans and Hispanics/Latinos accounted for 69% of HIV diagnoses but comprised only 31% of the U.S. population (Does not include 6 dependent areas)

  • 9 in 20: Black/African American
  • 5 in 20: Hispanic/Latino
  • 5 in 20: White
  • 1 in 20: Other
    • American Indian/Alaska Native: 0.6%
    • Asian: 2.5%
    • Native Hawaiian/Other Pacific Islander: 0.1%
    • Multiple races: 2.3%

Percentage of HIV Diagnoses in 2017

  • The South: 52%
  • The Northeast: 16%
  • The Midwest: 13%
  • The West: 19%
  • Less than 1% of HIV diagnoses are in the 6 U.S. dependent areas: American Samoa, Guam, Northern Mariana Islands, Puerto Rico, Republic of Palau, U.S. Virgin Islands
  • Male-to-Male Sexual Contact (MSM): 67%
  • Heterosexual Contact: 24%
  • IDU (Injection Drug Use): 6%
  • MSM/IDU: 3%

Centers for Disease Control and Prevention (CDC); National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Division of HIV/AIDS Prevention

Data include diagnoses from the U.S. and 6 dependent areas. Data for the year 2017 are preliminary and based on 6 months reporting delay. Please use CDC’s Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance data report for final year data.

Download the HIV Surveillance Report in PDF format