41,000 HIV transmissions yearly due to no diagnosis or care

Improving the diagnosis of HIV infection, and the level of contact with care services for those who are diagnosed, is as significant as targeting risky sexual and drug use behaviors for cutting the total estimated number of 45,000 HIV transmissions every year in the USA, found the authors of research published today.

Full care, including adherence to antiretroviral therapy, gave the best reduction in HIV transmission rates.

The study, in JAMA Internal Medicine, concludes that improving the health care reach, "primarily" to those HIV-infected people who are undiagnosed and not receiving antiretroviral therapy, "would have a substantial effect on HIV transmission in the United States."

Medical officials at the USA Centers for Disease Control and Prevention (CDC) in Atlanta, GA estimated the rate and number of HIV transmissions that could be attributed to each of 5 steps in the "care continuum" for patients.

The researchers used national databases for 2009 estimates, finding that in the USA that year, more than 1.1 million people were living with HIV. Of those:

1. The infected but undiagnosed people amounted to 207,600 (18.1%)
2. Diagnosed but not in medical care - 519,414 (45.2%)
3. Retained in medical care but not prescribed antiretroviral therapy (ART) - 47,453 (4.1%)
4. Prescribed ART but not virally suppressed - 82,809 (7.2%)
5. Achieved viral suppression - 290,924 (25.3%).

The definition used in the study for "retention in care" for people diagnosed with HIV infection was that they had completed "at least 1 visit with an HIV care provider during a single 4-month period in 1 calendar year."

The authors conclude: "In the United States, persons living with HIV who are retained in medical care and have achieved viral suppression are 94% less likely to transmit HIV than HIV-infected undiagnosed persons."

"Unfortunately, too few persons living with HIV have achieved viral suppression."

The authors add: "Improvements are needed at each step of the continuum to reduce HIV transmission."

The study concludes that goals to increase the number of people with HIV who know their status, get health care, and receive and adhere to ART, could be realized by the US with "meaningful gains" through "stronger coordination of efforts" among individuals, HIV care providers, health departments, government agencies.

The research found that those people infected with HIV but undiagnosed, plus those diagnosed with HIV but not in medical care, made up almost 92% of the estimated 45,000 transmissions in 2009 (61% were accounted for by the latter group not in contact with care services).

In addition to the 94% reduction in transmission achieved by full care, achieving the other care steps also reduced rates, the results of the study show.

Those people who were diagnosed but not retained in medical care, for example, were 19% less likely to transmit HIV than those who remained undiagnosed.

Stratifying risk of HIV transmission by sex, acquisition risk category and age group, the authors found that the following groups accounted for most transmissions:

• Men
• HIV acquisition via male-to-male sexual contact
• Age 35 to 44 years.

Viral load decreases as 'care cascade' progresses

A commentary article accompanying the study - written by a researcher who found in 2005 that just a quarter of HIV-infected people in the US were estimated to have achieved viral suppression - says that the current findings turn the "treatment cascade into an HIV prevention tool."

The results confirm what is apparent from a careful consideration of the cascade: as the cascade proceeds from undiagnosed HIV to viral suppression, the average viral load decreases, and there is a glut of persons lost in the cascade between diagnosis and retention in care.

Delayed diagnosis and inadequate retention in care are - "not surprisingly" - the steps of the cascade that "propel HIV transmission in the United States.

Medical officials propose more HIV testing among the solutions. (The CDC recommends universal screening of all adults and adolescents in routine health care settings, but "local practice and many Medicaid reimbursement policies are not consistent" with this.)

"Patient factors are clearly important determinants of the HIV treatment cascade. However, as care providers and administrators, we can improve the cascade by changing our own behavior and programs, even as we also try to influence patients' behavior."

Even simple customer care approaches could improve HIV-infected people's retention in medical care programs. Care should be efficient, courteous, patient-oriented and delivered in a welcoming environment.

In other HIV news, last week, a new, aggressive form of the virus was identified in Cuba. If undiagnosed HIV infection remains a challenge in the US, it is more so in developing countries, but a smartphone accessory has been developed that "diagnoses HIV and syphilis in 15 minutes."

Finally in other news last week, a novel drug candidate against HIV has been created.

References:

1.  Human immunodeficiency virus transmission at each step of the care continuum in the United States, Jacek Skarbinski, et al., JAMA Intern Med, doi:10.1001/jamainternmed.2014.8180, published online 23 February 2015, abstract.
2.  The HIV treatment cascade - a new tool in HIV prevention, Thomas Giordano, JAMA Intern Med, doi:10.1001/jamainternmed.2014.8199, published online 23 February 2015.