In the news ... 2008

Project Inform offers suggestions for
crafting National AIDS Strategy

by Dana Van Gorder, August 19, 2008

On August 2, 2008, the Centers for Disease Control (CDC) released long-awaited data on the estimated number of annual new cases of HIV infection in the United States. Having stagnated at some 40,000 cases per year for ten years, the CDC announced that it now estimates 56,000 new cases of HIV infection have been taking place yearly for the past several years. Hardest hit have been men who have sex with men (MSM), particularly MSM of color, and women of color. The new estimate did not entirely result from increased incidence among MSM, but from the implementation of more accurate HIV reporting systems by the states.

It was not a surprise that the estimate of HIV incidence (new cases of infection) increased, as this announcement had been anticipated for better than a year. But the actual number did come as a surprise, given rumors that the new estimate would be 50,000. And because several states do not yet have mature HIV names reporting systems, including California which is home to one-sixth of the nation’s HIV cases, the CDC made it clear that the actual new incidence figures could in fact be higher than 56,000.

In part because the CDC announcement was made on the eve of the International AIDS Conference in Mexico City, the new data received a considerable response. Some AIDS agencies were quick to peg this startling problem to inadequacies on the part of the federal government in the form of inadequate funding for prevention programs and ill-advised policies, including its push for abstinence-based sex and HIV education. Others, including Project Inform, reacted by saying that the federal role in prevention is not entirely adequate, but there are other urgent structural problems in HIV prevention, as well.

Despite years of prevention research and discussion about its meaning, neither government nor community-based organizations appear to agree upon a focused set of prevention strategies that might have deeper impact on HIV incidence. The diffuse nature of decision making and funding for prevention do not necessarily encourage the kind of focus and coordination that might further reduce incidence. Prevention funding does not always seem to be adequately targeted to those populations at greatest risk for HIV infection. Funders are not demanding thorough evaluation of the impact of current prevention programs.

The CDC release also became a vehicle for discussion of the push, which Project Inform is helping to lead, for the next President to convene a panel to develop a National AIDS Strategy within one year of taking office. Organizers of the effort hope for a Strategy that, instead of being a laundry list of all of the things that could be done to address HIV, identifies a limited number of highly focused, truly strategic steps that are needed to increase the number of HIV-positive people who are in care and treatment, reduce health disparities for people of color and women, and reduce HIV incidence.

Senator Obama responded to the CDC data by committing himself to the development of a National AIDS Strategy if he is elected President. Senator McCain stopped short of endorsing the Strategy, but indicated that, as President, he would seek guidance from a broad array of HIV experts to reduce incidence and make greater progress against the epidemic. Additional conversations are taking place with both campaigns about their commitment to the Strategy and to its inclusion in the platforms of both parties.

From Project Inform’s perspective, several potential bio-medical approaches to HIV prevention should be considered for inclusion in the National AIDS Strategy. Evidence is clear and compelling that acute HIV infection – the set of clinical events that mark the earliest days and weeks of HIV infection – should be a target of a significant community and provider education both to benefit the HIV-positive individual and prevention simultaneously. HIV-positive people are highly infectious during this early state of infection lasting up to perhaps three months, and most experience symptoms of infection. And yet, many at-risk individuals do not know that this is an important time to respond with appropriate medical care and prevention behaviors. And many clinicians fail to connect the flu-like symptoms that patients experience during acute infection as stemming from possible exposure to HIV. The potential impact on incidence of an effort to educate about acute infection has been long talked about. It is time to move forward with such a strategy.

We have spoken in previous issues of PIP eNews about the potential for Pre-Exposure Prophlaxis (PrEP) to have significant impact on HIV prevention, as well. Currently subject to clinical studies, PrEP would involve providing HIV medications – Viread (tenofovir) and Truvada are current candidates – to high-risk HIV-negative individuals, together with behavioral counseling, to add protection against HIV. A host of issues surround the implementation of such an effort, and Project Inform is part of a national working group working to consider and address them. Exploring the potential for PrEP to significantly reduce HIV incidence and preparing to make it available based upon the success of clinical trials should be a central point of a meaningful National AIDS Strategy.

The idea that encouraging expanded and earlier treatment of HIV-positive people for HIV infection might not only improve their clinical outcomes but reduce incidence is a subject of much discussion – and some controversy – today. A review of studies that was commissioned by the Swiss government of mixed-status heterosexual couples suggested that, when the HIV-positive partner’s viral load is undetectable and neither partner has STDs, HIV transmission is highly unlikely to take place. Prevention agencies have expressed understandable concerns about the results of the study, fearing that it will cause HIV-positive people receiving treatment to discontinue condom use. But Project Inform believes it is critical that there is a national discussion about the potential to encourage high-risk people to learn their HIV status and for HIV-positive people to treat HIV earlier than currently recommended, together with practicing safe sex, to improve clinical outcomes for the positive individual and reduce transmission. We will be organizing a significant meeting on this subject in Spring 2009. Support for the development of such an approach should be another key element of the National AIDS Strategy.

Finally, it is well known that needle exchange programs constitute one of the most effective forms of HIV prevention available. The National AIDS Strategy should clearly support the elimination of barriers to the legality and funding of this lifesaving approach to prevention.

In addition to supporting the bio-medical prevention of HIV, Project Inform continues to be heavily focused on the development of strategies to increase HIV testing behaviors in the United States, support HIV-positive people to make sound treatment decisions, encourage the development of increasingly effective medications and a cure for HIV infection, and assure that all HIV-positive people have access to comprehensive, quality health care and treatment for HIV. In the next issue of PIP eNews, we will discuss our goals for the potential inclusion in the National AIDS Strategy of efforts that would address urgent needs in these critical areas.

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