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Connecting the Dots to an AIDS-Free Generation

Baligh Yehia, MD, MSHP, MPP, is a fellow in the division of Infectious Diseases in the Perelman School of Medicine. He attended this week's XIX International AIDS Conference and shared his thoughts about the work that lies ahead in the quest to eradicate HIV:

Baligh_whitecoat_smallThis week, HIV advocates, scientists, and patients gathered at the XIX International AIDS Conference in Washington, D.C. – the first time in 22 years the meeting was held in the United States. The group’s charge: mapping out a strategy to usher in an AIDS-free generation. The speakers came from all corners of the world, from politics and medicine to pop culture and business – Secretary of State Hillary Clinton, Senator John Kerry, President of the World Bank Dr. Jim Yong Kim, Sir Elton John, and Bill Gates among them – with a shared purpose. All highlighted the progress we have made since the last time the conference was held in the United States, and talked about the opportunity to, finally, turn the tide on HIV and AIDS. As the director of the National Institute of Allergy and Infectious Diseases (NIAD), Dr. Anthony Fauci stated, we’re in an era of unprecedented hope for this disease: “We are on scientifically solid ground when we say we can end the HIV/AIDS pandemic.”

The challenge of ending AIDS lies in connecting the dots – linking individuals, communities and countries with the right tools to prevent and treat HIV infection while combating the stigma, discrimination, fear, and lack of education that both contribute to its spread and keep people from being diagnosed and obtaining medical care once they’ve been infected. Overcoming these obstacles is not trivial, and conquering them requires dramatic changes in HIV testing and care access, adherence to prevention strategies and therapies to treat the disease, and advocacy. To even start discussing the possibility of an AIDS-free generation, we must answer some key questions. Among them: What are the best strategies for keeping people in care? How do we help individuals who to choose to take HIV drugs for prevention purposes adhere to these drugs and get regular HIV testing? How do we develop timely and impactful public policy to minimize HIV prevention and treatment barriers?

These questions represent only some of the barriers facing people living with HIV, their doctors, and health systems. I’m part of a national research team that works on finding solutions to some of these difficult questions. In a study appearing in this week’s Journal of the American Medical Association (JAMA), our group analyzed 32,483 HIV-infected patients cared for in 12 clinics across the United States between 2001 and 2010. During that time, the percentage of patients taking antiretroviral drugs who exhibited sustained viral suppression – having no detectable HIV virus in the blood every time the virus is measured – increased from 45 percent to 72 percent. Despite this increase, the number of patients with tightly controlled HIV infection was significantly less than the 77 percent to 87 percent figures reported in prior studies, which were based on one-time only measures of HIV virus in the blood, rather than taking into account trends across each time the virus was measured.

These lower percentages likely indicate that patients are having difficulty accessing and adhering to care and treatment. To be sure, the figures represent progress, especially since death rates from HIV have plummeted during the same timeframe, and the drugs have turned HIV into a chronic, manageable disease for many patients who take them. But they also shed light on the challenges that exist in other parts of the globe: If less than a three-quarters of patients in the resource-rich United States have difficulty maintaining HIV viral suppression, how much more difficult is it for patients in non-industrialized, poor parts of the world? In most parts of the United States, HIV-infected patients are able to obtain free (or almost free) medications and care through insurance programs, such as Medicaid and Medicare, or the Ryan White Program, for those patients without any insurance; while in Nigeria, Indonesia, and Cameroon less than 30 percent of individuals eligible for treatment are on life saving HIV medications. They face unimaginable barriers to care – poverty, hunger, transportation problems, stigmas, and not enough care providers to go around.

Given those issues, can we truly say that we are turning the tide on HIV? Bill Gates said he isn’t so sure: “Is the end clearly in sight? No. Do we have the tools that will bring about the end? No. There is a very good chance it will be a decade plus before we’ll have the thing” to finally halt its spread, like a vaccine. I tend to agree. Connecting the dots won’t be an easy task, but what is reassuring is that for the first time, scientists are using the phrase “functional cure” in earnest, the methods for prevention the spread of the virus are rapidly improving, and countries across the globe are providing a more efficient and effective response to the HIV/AIDS epidemic. 

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