Rethinking HIV: After Five Years of Debate, a New Push for Prevention

After decades of focusing almost exclusively on treating HIV, public health experts are finally able to add more effective prevention strategies to curb spread of the disease.

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After decades of focusing almost exclusively on treating HIV, public health experts are now considering a new approach, moving to establish more effective prevention strategies to curb spread of the disease. Recent tests show that anti-HIV drugs that can hamper the growth of the virus responsible for AIDS may also prevent progression of the disease if given to infected individuals soon after their exposure to HIV. The same drugs can also prevent infections from taking hold among healthy people who are exposed to the virus; both approaches would be critical ways of controlling spread of the virus and keeping new cases of HIV to a minimum.

With this potential in mind, the U.S. Preventive Services Task Force (USPSTF) issued a draft recommendation urging that all people between the ages of 15 and 65 be tested for the virus as part of routine health screening, even if they are not at  high risk of exposure to HIV.

(MORE: Treatment as Prevention: How the New Way to Control HIV Came to Be)

The independent panel of health experts examined recent scientific evidence, including trials that aimed to use anti-HIV drugs to prevent the disease (so-called pre-exposure prophylaxis), and concluded that prompt diagnosis leads to earlier use of effective treatments — and more promising outcomes. Their conclusion: Making HIV screening as routine as cholesterol testing will allow more people to know their status and take advantage of favorable therapies. One in five people living with HIV in the U.S. are not aware of their positive status, and even among those at higher risk, such as gay and bisexual men, testing rates are low: nearly 75% had received medical care but 48% were not tested for HIV, according to the Centers for Disease Control (CDC).

(MORE: Early Treatment With Anti-HIV Drugs Stops Transmission Between Partners)

The task force released a draft of their recommendation proposal, which is open to public comments through December 17. The new guidelines recommend doctors screen individuals over age 15 and under 65 as well as all pregnant women. “Screening individuals between ages 15 and 65 is likely to improve the health of the population because it’s going to find people that don’t know they’re positive,” says Dr. Virginia Moyer, the chair of the task force and pediatrics professor at Baylor College of Medicine. “What we didn’t know when we made our previous recommendation that we know now is that treatment earlier in the course of the infection can substantially improve outcomes.”

(MORE: HIV Drugs May Prevent Infection In Health Individuals)

That knowledge is helping public health campaigns to adopt more prevention strategies and shift away from focusing primarily on treatment as the way to stop the spread of HIV. And it provides campaigns leverage to promote  measures beyond safe sex and abstinence, which have only been marginally effective in reducing new infection rates. “The fact is that the best way to deal with HIV is don’t get it in the first place,” says Moyer. “Yes, we can screen and treat, and it makes a difference, but it still involves treatment that if you could avoid it, you wouldn’t want to have. If we can really focus on prevention, that would be great.”

(MORE: U.S. Panel Recommends More Routine HIV Testing)

Since 2006, the CDC has pushed for more widespread HIV testing for patients as young as 13, citing the fact that many are unaware they are living with HIV, and that available therapies can extend their lives, especially if begun early. In 2005, the task force recommended screening for adolescents and adults who were at a high risk for HIV. But it wasn’t until 2011, when the latest studies on the power of AIDS drugs to prevent infection were released, that health officials could begin devising practical ways of making prevention a priority. “We started looking at getting treatments before symptoms and it turns out it does improve things,” says Moyer. “Our treatments have gotten better and they’ve gotten easier. All those things have worked together to change the balance so that it now appears that general screening makes it likely that across the whole population we will have healthier people.”

(MORE: AIDS Trial Halted: Anti-HIV Pill Fails to Protect Women)

According to Kali Lindsey, director of legislative and public affairs for the National Minority AIDS Council (NMAC), which provides information and research to public health clinics, the recent trial results, and the USPSTF recommendation represent a critical change in managing HIV. “Despite decades of behavioral interventions, infection rates have remained relatively stable, and are increasing among gay and bisexual men, especially young black gay men,” says Lindsey. “Treatment as prevention, pre-exposure prophylaxis, and microbicides offer exciting new ways to slow the spread of HIV. But no prevention strategy can truly be effective without an expanded push for scaled-up HIV screening.”

The shift in emphasis toward prevention is timely as well, since combination drug therapies have created a sense of complacency about the disease that continues to fuel 50,000 new infections each year even in the U.S. About 20% to 25% of people living with HIV are unaware they are HIV positive.

“The general sense of urgency around HIV/AIDS seems to have dissipated,” says Lindsey. “Much of this has to do with improvements in treatment that have made it possible for those who can access it to live long, relatively healthy lives.  But some of this also has to do with a perception that has persisted since the onset of the epidemic–that HIV is a disease of ‘others.’ That it only affects gay men or injection drug users. Too many people underestimate their own vulnerability to infection.”

(MORE: How the Global War on Drugs Drives HIV and AIDS)

That might change if testing for HIV became routine. “I don’t think most Americans realize how serious this epidemic remains,” says Chris Collins, vice president and director of public policy for amfAR, The Foundation for AIDS Research. “The good news is we have the tools, including testing, treatment and targeted prevention that could really begin to end this epidemic in America. The question is whether we get those interventions to the people who need it.”

Testing for HIV is the first step toward expanding those interventions. “This recommendation and its approval will be one more important step towards reducing the stigma of HIV testing both for people in the general public so they are more likely to get a test, and for healthcare providers who currently don’t offer the test automatically because they don’t perceive their client to be at risk, or they don’t want to talk about sex and sexuality,” says Collins.

Collins say normalizing testing and making it an active part of quality medical care will greatly expand the reach of testing and identify more people in need of treatment. As part of a preventive health care strategy, the routine HIV testing would be reimbursed by insurers under President Obama’s proposed health care program; currently only those at highest risk are not required to provide a co-pay for the HIV test. “We have to make sure it is reimbursed in all cases so that financial concerns never stand in the way of a doctor offering a test and person accepting it,” Collins says. “This proposal is an important step towards that.”

(MORE: Truvada: 5 Things to Know About the First Drug to Prevent HIV)

Recent developments, like the first at-home HIV test OraQuick–which can identify antibodies that signal HIV infection from saliva in 20 minutes–also helps reduce stigma around the disease. “Any development that normalizes HIV testing is exciting,” says Lindsey. “The last couple of years have brought a number of exciting developments in our fight against HIV. From health care reform and the National HIV/AIDS Strategy to treatment as prevention and pre-exposure prophylaxis, science and policy have aligned like never before, making it possible to realistically envision an end to this epidemic.”

Collins agrees that the recommendations represent a first step toward turning around the AIDS epidemic in the U.S. “These policy changes mean we can really can start to talk about the end of AIDS,” he says.