Opinion
VIEWPOINT
Anthony S. Fauci, MD National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland. Hilary D. Marston, MD, MPH National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland.
Viewpoint page 359
Corresponding Author: Anthony S. Fauci, MD, National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID), Building 31, Room 7A-03, 31 Center Drive, MSC 2520, Bethesda, MD 20892-2520 ([email protected]).
Focusing to Achieve a World Without AIDS More than a decade ago, the global AIDS community was working toward what was considered at the time to be an audacious goal: “3 by 5” or initiating combination antiretroviral therapy (ART) for 3 million people by 2005. The rollout of ART to millions of people in poverty-stricken nations seemed extremely problematic, and many critics were concerned that the 3 by 5 goal was unrealistic. Today, an estimated 13.6 million people worldwide are receiving ART, 700 000 having initiated therapy over the past year alone—remarkable progress by any measure.1 Although much remains to be done to achieve universal global access to ART for all people with human immunodeficiency virus (HIV), the global AIDS community has set its sights on new, even more ambitious goals. Specifically, the new goals are the “90-90-90” targets: by 2020, 90% of all people living with HIV should know their HIV status, 90% of those who test positive for HIV should be provided therapy, and of those, 90% should achieve virologic suppression (levels of virus below those detectable by standard tests).1 Achieving these targets would be a major step toward a world without AIDS. As the clinical and public health communities work toward these targets, the “traditional” approach of broad, population-based rollout of treatment and prevention messages and technologies must be reexamined and different approaches must be considered. It is important to learn lessons from successful disease control programs like those for smallpox and polio—as the final goal becomes closer, efforts must become more specific and focused. Scale must give way to details. Those details will take several forms. For example, a specific understanding of the relationship between geographic sublocation and disease prevalence will allow heavy targeting of interventions more precisely to areas with high incidence. Jones and colleagues2 recently discussed how HIV risk is not evenly distributed; rather, it is located in multiple microepidemics. For example, although national adult HIV prevalence in Kenya is 5.6%, in hyperendemic areas near Lake Victoria, those rates can exceed 15%. Under such circumstances, blanket, uniform distribution of resources throughout a country without attention to relative disparities in disease intensity seems to be a suboptimal use of resources. A United Nations Joint Program on HIV/AIDS (UNAIDS) model indicates that targeted introduction of tailored prevention packages could avert 600 000 additional infections by 2030, using the same budget currently deployed for national programming.3 Within specific geographies, risk distribution is variable. For example, within the United States, men who have sex with men (MSM) remain a key risk
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demographic for HIV infection. However, the HIV seroprevalence is 4 times higher among black MSM than among white MSM (32% for black MSM vs 8% for white MSM), and the proportion achieving virologic suppression is 50% lower (16% for black MSM vs 34% for white MSM). 4 The AIDS response in the United States is failing MSM, particularly black MSM. In addition, risk varies by stage of disease and a patient’s ability to access, and remain in, medical care. However, the continuum of care for most people with HIV is not a straight progression from diagnosis, to entry into care, to initiation of ART, to virologic suppression. Recent data from the Centers for Disease Control and Prevention (CDC) indicate that less than one-third of individuals living with HIV in the United States have achieved virologic suppression— that is, roughly 360 000 of 1.2 million infected individuals.5 Among the 840 000 individuals without virologic suppression in 2011, more than 60% had been previously diagnosed, but were not retained in care, and, ideally, would have been enrolled in treatment and maintained virus-suppressing ART.5 Overall, 86% of individuals with HIV in the United States know their infection status; still the health care system is failing to control their disease.5 This leaves them vulnerable to unnecessary illness and represents a missed opportunity to prevent further transmission of the virus. To reach the 90-90-90 goals in the United States and globally, focus should be on the populations most vulnerable to HIV and should target interventions that are most useful and sustainable for these people. Simultaneously, infected individuals and health care practitioners must work together to understand the gaps in the continuum of care and the best ways to fill them. In addition, specific interventions should be tailored to the demography that drives microepidemics. For example, where MSM transmission is common, preexposure prophylaxis (PrEP) could play an important role (among other interventions). Recent guidelines from the US Public Health Service and the CDC,6 as well as the World Health Organization, 7 recommending routine use of PrEP for at-risk individuals could curb new infections. Long-acting antiretrovirals and alternative prescribing regimens could improve PrEP effectiveness among target populations. Where heterosexual transmission is common, particularly in low- and mid-income countries such as in southern Africa, voluntary male medical circumcision, PrEP, and HIV microbicides could prove useful. The latter are now being tested for use in vaginal rings, with or without contraceptives. These sorts of tools could target the needs of young women looking to take control of their sexual health. (Reprinted) JAMA January 27, 2015 Volume 313, Number 4
Copyright 2015 American Medical Association. All rights reserved.
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357
Opinion Viewpoint
Ultimately, the tailored deployment of these interventions against HIV, along with a robust system of care and treatment to help individuals achieve and maintain virologic suppression, will be essential to attain a world without AIDS. Even though the United States and the global community are currently far ARTICLE INFORMATION Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. United Nations Joint Program on HIV/AIDS (UNAIDS). Fast-Track—ending the AIDS epidemic by 2030. http://www.unaids.org/en/resources /documents/2014/JC2686_WAD2014report. Accessed December 1, 2014. 2. Jones A, Cremin I, Abdullah F, et al. Transformation of HIV from pandemic to
358
from that goal, with a commitment to scaling up both provision of ART and proven prevention interventions, as well as a strategic focus on the communities and individuals most at risk, important progress can be made in the struggle toward a world without AIDS.
low-endemic levels: a public health approach to combination prevention. Lancet. 2014;384(9939): 272-279. 3. UNAIDS. Issues brief: local epidemics. http://www .unaids.org/sites/default/files/media_asset/JC2559 _local-epidemics_en.pdf. Accessed December 1, 2014. 4. Rosenberg ES, Millett GA, Sullivan PS, Del Rio C, Curran JW. Modeling disparities in HIV infection between black and white men who have sex with men in the United States using the HIV care continuum. Lancet HIV. 2014;1(3):e112-e118. 5. Bradley H, Hall HI, Wolitski RJ, et al. Vital signs: HIV diagnosis, care, and treatment among persons
living with HIV—United States, 2011. MMWR Morb Mortal Wkly Rep. 2014;63(47):1113-1117. 6. US Public Health Service and CDC. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. http://www.cdc.gov/hiv/pdf /PrEPguidelines2014.pdf. Accessed December 1, 2014. 7. World Health Organization. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. http://apps.who.int /iris/bitstream/10665/128048/1/9789241507431 _eng.pdf?ua=1&ua=1. Accessed December 1, 2014.
JAMA January 27, 2015 Volume 313, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a J H Quillen College User on 05/30/2015
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VIEWPOINT
Anthony S. Fauci, MD National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland. Hilary D. Marston, MD, MPH National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland.
Viewpoint page 359
Corresponding Author: Anthony S. Fauci, MD, National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID), Building 31, Room 7A-03, 31 Center Drive, MSC 2520, Bethesda, MD 20892-2520 ([email protected]).
Focusing to Achieve a World Without AIDS More than a decade ago, the global AIDS community was working toward what was considered at the time to be an audacious goal: “3 by 5” or initiating combination antiretroviral therapy (ART) for 3 million people by 2005. The rollout of ART to millions of people in poverty-stricken nations seemed extremely problematic, and many critics were concerned that the 3 by 5 goal was unrealistic. Today, an estimated 13.6 million people worldwide are receiving ART, 700 000 having initiated therapy over the past year alone—remarkable progress by any measure.1 Although much remains to be done to achieve universal global access to ART for all people with human immunodeficiency virus (HIV), the global AIDS community has set its sights on new, even more ambitious goals. Specifically, the new goals are the “90-90-90” targets: by 2020, 90% of all people living with HIV should know their HIV status, 90% of those who test positive for HIV should be provided therapy, and of those, 90% should achieve virologic suppression (levels of virus below those detectable by standard tests).1 Achieving these targets would be a major step toward a world without AIDS. As the clinical and public health communities work toward these targets, the “traditional” approach of broad, population-based rollout of treatment and prevention messages and technologies must be reexamined and different approaches must be considered. It is important to learn lessons from successful disease control programs like those for smallpox and polio—as the final goal becomes closer, efforts must become more specific and focused. Scale must give way to details. Those details will take several forms. For example, a specific understanding of the relationship between geographic sublocation and disease prevalence will allow heavy targeting of interventions more precisely to areas with high incidence. Jones and colleagues2 recently discussed how HIV risk is not evenly distributed; rather, it is located in multiple microepidemics. For example, although national adult HIV prevalence in Kenya is 5.6%, in hyperendemic areas near Lake Victoria, those rates can exceed 15%. Under such circumstances, blanket, uniform distribution of resources throughout a country without attention to relative disparities in disease intensity seems to be a suboptimal use of resources. A United Nations Joint Program on HIV/AIDS (UNAIDS) model indicates that targeted introduction of tailored prevention packages could avert 600 000 additional infections by 2030, using the same budget currently deployed for national programming.3 Within specific geographies, risk distribution is variable. For example, within the United States, men who have sex with men (MSM) remain a key risk
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demographic for HIV infection. However, the HIV seroprevalence is 4 times higher among black MSM than among white MSM (32% for black MSM vs 8% for white MSM), and the proportion achieving virologic suppression is 50% lower (16% for black MSM vs 34% for white MSM). 4 The AIDS response in the United States is failing MSM, particularly black MSM. In addition, risk varies by stage of disease and a patient’s ability to access, and remain in, medical care. However, the continuum of care for most people with HIV is not a straight progression from diagnosis, to entry into care, to initiation of ART, to virologic suppression. Recent data from the Centers for Disease Control and Prevention (CDC) indicate that less than one-third of individuals living with HIV in the United States have achieved virologic suppression— that is, roughly 360 000 of 1.2 million infected individuals.5 Among the 840 000 individuals without virologic suppression in 2011, more than 60% had been previously diagnosed, but were not retained in care, and, ideally, would have been enrolled in treatment and maintained virus-suppressing ART.5 Overall, 86% of individuals with HIV in the United States know their infection status; still the health care system is failing to control their disease.5 This leaves them vulnerable to unnecessary illness and represents a missed opportunity to prevent further transmission of the virus. To reach the 90-90-90 goals in the United States and globally, focus should be on the populations most vulnerable to HIV and should target interventions that are most useful and sustainable for these people. Simultaneously, infected individuals and health care practitioners must work together to understand the gaps in the continuum of care and the best ways to fill them. In addition, specific interventions should be tailored to the demography that drives microepidemics. For example, where MSM transmission is common, preexposure prophylaxis (PrEP) could play an important role (among other interventions). Recent guidelines from the US Public Health Service and the CDC,6 as well as the World Health Organization, 7 recommending routine use of PrEP for at-risk individuals could curb new infections. Long-acting antiretrovirals and alternative prescribing regimens could improve PrEP effectiveness among target populations. Where heterosexual transmission is common, particularly in low- and mid-income countries such as in southern Africa, voluntary male medical circumcision, PrEP, and HIV microbicides could prove useful. The latter are now being tested for use in vaginal rings, with or without contraceptives. These sorts of tools could target the needs of young women looking to take control of their sexual health. (Reprinted) JAMA January 27, 2015 Volume 313, Number 4
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a J H Quillen College User on 05/30/2015
357
Opinion Viewpoint
Ultimately, the tailored deployment of these interventions against HIV, along with a robust system of care and treatment to help individuals achieve and maintain virologic suppression, will be essential to attain a world without AIDS. Even though the United States and the global community are currently far ARTICLE INFORMATION Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. United Nations Joint Program on HIV/AIDS (UNAIDS). Fast-Track—ending the AIDS epidemic by 2030. http://www.unaids.org/en/resources /documents/2014/JC2686_WAD2014report. Accessed December 1, 2014. 2. Jones A, Cremin I, Abdullah F, et al. Transformation of HIV from pandemic to
358
from that goal, with a commitment to scaling up both provision of ART and proven prevention interventions, as well as a strategic focus on the communities and individuals most at risk, important progress can be made in the struggle toward a world without AIDS.
low-endemic levels: a public health approach to combination prevention. Lancet. 2014;384(9939): 272-279. 3. UNAIDS. Issues brief: local epidemics. http://www .unaids.org/sites/default/files/media_asset/JC2559 _local-epidemics_en.pdf. Accessed December 1, 2014. 4. Rosenberg ES, Millett GA, Sullivan PS, Del Rio C, Curran JW. Modeling disparities in HIV infection between black and white men who have sex with men in the United States using the HIV care continuum. Lancet HIV. 2014;1(3):e112-e118. 5. Bradley H, Hall HI, Wolitski RJ, et al. Vital signs: HIV diagnosis, care, and treatment among persons
living with HIV—United States, 2011. MMWR Morb Mortal Wkly Rep. 2014;63(47):1113-1117. 6. US Public Health Service and CDC. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. http://www.cdc.gov/hiv/pdf /PrEPguidelines2014.pdf. Accessed December 1, 2014. 7. World Health Organization. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. http://apps.who.int /iris/bitstream/10665/128048/1/9789241507431 _eng.pdf?ua=1&ua=1. Accessed December 1, 2014.
JAMA January 27, 2015 Volume 313, Number 4 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a J H Quillen College User on 05/30/2015
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