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Reprioritizing HIV: A Q&A with Med Student Robert Bonacci

RBonacci_Headshot (4)Last week, a study on the falling HIV infections rates in the U.S. from Perelman School of Medicine student Robert Bonacci delivered good news, but it also presented a reality about the shortcomings in the nation’s strategy to combat the disease, as well as the health disparities that exist today.  “The research was an important first step so we could understand our failures and successes and use them to reprioritize our efforts,” he said. 

A conversation with Bonacci, who’s just a week away from adding MD to his name, revealed more about where we went wrong and right, some good advice for the next president, what we can learn from other developed—and developing—nations, and why he gravitates toward public health.

Your study in AIDS and Behavior found that HIV infections and transmission rate dropped, but fell short of the goals outlined in the 2010 U.S. National HIV/AIDS Strategy. While a reduction is a promising finding, why do you think the U.S. didn’t reach its goals?

That the number of HIV infections per year and the transmission rate are decreasing is encouraging news, but work remains to be done. We fell about halfway short on key goals in the U.S. National HIV/AIDS Strategy (2010-2015). Overall, the strategy was a tremendous step forward, one that has motivated stakeholders at the federal, state, and local levels to think about how we can better coordinate and prioritize our response to the HIV epidemic. However, one area where the National HIV/AIDS Strategy could have benefited is by addressing the costs and resource inputs necessary to achieve strategy goals. At the end of the day, we didn’t make the necessary investments to scale up HIV diagnostic and prevention programs to the levels needed.

The White House updated their strategy for 2020, and we’re about to nominate a new president this fall. What do you think has to happen over the next four years to help us achieve the set goals?

Foremost, I believe the next presidential administration should adopt and carry forward the updated National HIV/AIDS Strategy. I’d also add that the next administration should strongly consider adding back a target for HIV incidence, which was removed in the update to 2020.

Another important step to achieving the goals of the updated strategy is to provide estimates on the resources needed. This way, the administration can work with Congress to make the requisite investments to deliver expanded HIV services. This should include an expansion of HIV diagnostic and prevention services, which haven’t grown as robustly as treatment and care. Perhaps most important, we must intensify our focus on reaching communities disproportionately affected by HIV, particularly gay men, young people, transgender people, African American and Hispanic communities, and those who live in the Southern U.S.

Many nations have strategies to improve HIV rates, care, prevention, etc. How does the United States stack up against those countries? Are there efforts in other countries that may prove effective here in the U.S.?

With our first comprehensive National HIV/AIDS Strategy and the subsequent update, I believe the U.S. is on the right track. We were one of the first nations to recommend antiretroviral therapy (ART) for all persons with HIV, regardless of CD4 count, and have played a key role in many landmark HIV developments, including treatment as prevention and pre-exposure prophylaxis. However, we certainly have much to learn about implementing those innovations and basic healthcare in a way that meets the needs of our communities and maximizes impact.

Both high and low-income countries have important lessons to offer. One area we struggle with in the U.S. is helping people along the path of HIV care (and by that, I mean how do we make individuals aware of their HIV infection, connect them to medical care, get them on ART, and ultimately achieve undetectable levels of virus in their bodies). While many countries in sub-Saharan Africa lack financial and healthcare resources, some have innovated low cost, creative ways to ensure that citizens can get the HIV care and medications they need to live and prevent further transmission.

Another key issue for persons living with HIV in the U.S. is access to care. Medicaid expansion has largely not reached the Southern U.S., where our HIV epidemic is most intensified. Universal healthcare in countries like Canada and the Great Britain offer lessons on the benefits of expanded coverage for addressing the HIV epidemic.

You conducted this research alongside David Holtgrave, PhD, chair of the department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health, whom you met while completing your Masters of Public Health at Hopkins.  What motivated you to pursue this research and a MPH degree?

I recognized early in my training that there was an indispensable link between our patients and their illnesses and the many forces that act on their lives beyond hospital walls (what are known as the social determinants of health).

Having spent some years of my training thinking about how the social determinants affect my patients’ health at a community level, I wanted to learn more and gain research tools to study public health policies and systems that promote disease prevention among our vulnerable communities. For these reasons, I decided that a MPH degree would be an important addition to my training.

As an undergraduate and medical student, I have spent the past eight years researching the prevention and epidemiology of HIV and tuberculosis. I was drawn to studying these two globally devastating epidemics because they disproportionately affect our poorest and most vulnerable communities, both in the U.S. and abroad. With that in mind, I saw this HIV policy research as an important first step in evaluating the original National HIV/AIDS Strategy so that we could understand our failures and successes and use them to reprioritize our efforts to address the HIV epidemic for the second era of the National HIV/AIDS Strategy.

After getting your MPH, you came back to Perelman to finish your fourth year of medical school. What’s next for you?

Well, graduation is coming up fast (May 15)! In June, I move to Boston where I will spend the next three years as an internal medicine resident at the Brigham and Women’s Hospital. While there, I hope to continue developing my clinical acumen and expand my infectious diseases research and global health work. In the long term, I certainly hope to be working at the intersections of clinical medicine and public health. I look forward to many more years of learning and thinking about how our growing body of prevention and epidemiology research for HIV, TB, and other diseases can be implemented as smart public health policies that secure the health of our most vulnerable communities in the U.S. and abroad.

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