Professor of Medicine
School of Medicine
Site Leader, Global Infectious Diseases
Clinical Trials Unit
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
David A. Wohl, MD, has disclosed that he has served on advisory boards for and received funds for research support from Gilead Sciences, Merck, and ViiV Healthcare.
Underway is an ambitious initiative, roping in major public health entities within the federal government, to substantially reduce new HIV infections in the United States. Following the 63-word announcement embedded in the February 2019 State of the Union Address, details of the plan emerged on the Health Resources and Services Administration Web site. The underpinning of the initiative was simple, with 4 pillars guiding the strategy: early diagnosis, early and durable treatment, prevention with pre-exposure prophylaxis (PrEP), and epidemiology-driven response to detect and react to new clusters of infections.
Skepticism of a bold administration promise made during a contentious address, which was itself controversial and was postponed following a government shutdown, is understandable. Today, nearly a year later, there remain concerns that the plan is underfunded and suspicion as its architects simultaneously impede access to HIV testing, prevention, and treatment by attacking the Affordable Care Act and Planned Parenthood.
While we wait to see what the “Ending the HIV Epidemic” plan achieves, an examination of its central pillars and their relative benefits is appropriate. Both PrEP and treatment as prevention (TasP), along with earlier detection and treatment, have been credited with the approximately 20% decline in new HIV diagnoses over the last decade (from 48,785 in 2007 to 38,789 in 2017).
At IDWeek 2019, the findings of an analysis of the contributions of PrEP and TasP to trends in new HIV diagnoses in US metropolitan statistical areas (MSAs) were presented. Data from the CDC, the census, and prescription and claims databases were used to calculate in 105 MSAs HIV incidence rates, PrEP use among those with an indication, proportion of people living with HIV who have achieved viral suppression, and, ultimately, the relative impact of PrEP and TasP on HIV incidence.
Over the period of evaluation, 2012-2017, HIV incidence in these MSAs dropped substantially. At the same time, PrEP uptake rose dramatically among those with an indication, and viral suppression rates also climbed. A Poisson regression model reflecting the changes in rate for each MSA over time after adjustment for the effect of PrEP and TasP was used to determine the relative contribution of each strategy. According to this model, PrEP accounted for 6% (ie, more than one third) of the overall 15% drop in HIV diagnoses in these cities over this period compared with 3% for TasP. In addition, HIV incidence declined at a faster pace in the areas where PrEP uptake was greater, independent of TasP. Extrapolating these findings, the presenters estimate that HIV incidence in these cities will fall by 41% in 2022 if PrEP uptake among those with an indication increases by 50%.
It should be emphasized that the period of analysis is one in which PrEP uptake was dramatically rising, while the effect of better HIV therapies on viral suppression was leveling out. Of importance, the data also point to forces beyond PrEP and TasP that accounted for declines in new HIV diagnoses. Finally, in the interest of full disclosure, it should be noted that this study was conducted by the manufacturer of antiretroviral agents used both for PrEP and HIV treatment.
The analysis, however, appears to reasonably highlight the value of PrEP use where it is needed and the potential for the combination of it and treatment to meaningfully reduce HIV incidence. While that may appear to be a validation of 2 of the pillars of the “Ending the HIV Epidemic” plan, it also points to the need for better access to both PrEP and treatment. The Ryan White CARE Act, which provides access to HIV care and services at low or no cost, has demonstrated that when healthcare is considered a basic human right rather than a commodity, it can best lead to substantially better personal and public health and reduce outcome disparities. PrEP and TasP are seeds that can grow and flourish best in the fertile soil of a national system that recognizes the right to healthcare as universal.
For additional details on PrEP and other key issues addressed at IDWeek 2019, review more Conference Coverage from CCO here.