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The NAPWA/TAEP HIV/AIDS POLICY REPORT
Early Access to Treatment: an Effective Tool to Prevent HIV
This past summer, the Centers for Disease Control and Prevention (CDC) released data that show the rate of new HIV infections in the United States is much higher than previously thought. Using new technology, the CDC has obtained a more accurate measure of HIV incidence (the number of new infections in a given year) and HIV prevalence (number of people living with the HIV/AIDS overall) in this country. The CDC now estimates that there are 56,300 new infections a year; the previous estimate was 40,000 new infections annually. The long and the short of it is that HIV/AIDS is an even bigger cause for concern in the United States than we thought.
In response to the newly released CDC data, the U.S. House of Representatives Committee on Oversight and Government Reform held a congressional hearing. Many important suggestions were offered on how to improve HIV prevention efforts. Two strategies stood out: (1) redoubling our HIV testing efforts, including finding new ways to ensure that everyone is tested for HIV and (2) offering universal access to treatment for everyone who is HIV positive to reduce HIV transmission.
During the congressional hearing, CDC director Julie Gerberding, MD, MPH, testified that far too many people living with HIV and those at risk for contracting HIV are not being reached by prevention programs. The latest data show that 21 percent of people living with HIV/AIDS in the United States are unaware of their infection. These people are believed to be responsible for more than half of new HIV infections in the United States as a result of unknowingly transmitting the virus.1 In addition, too many people learn they have HIV when they are diagnosed with AIDS, meaning that they were infected for years and not aware of their status. Sadly, this raises the possibility that they have also unknowingly passed along HIV to others. Breaking the cycle of ignorance may help break the cycle of new infections. Sixteen years ago, the National Association of People with AIDS (NAPWA) launched National HIV Testing Day because we believe that taking an HIV test makes it possible for us to protect ourselves and those we love.
David Holtgrave, professor and chair of the Department of Health, Behavior and Society at Johns Hopkins Bloomberg School of Public Health in Baltimore, also presented at the congressional hearing. According to Holtgrave, for every 100 people living with HIV in the United States, there are just under five new infections on average in a year. That means that more than 95 percent of people living with HIV in America are not transmitting the virus to someone else in a given year.2
This information provides the fundamental basis for a prevention strategy that starts with HIV diagnosis. NAPWA supports a strategy whereby medical providers routinely offer an HIV test to all their patients, regardless of their perceived (or lack thereof) risk for HIV. The old approach of only testing individuals who we think might be at risk for HIV is failing to reach countless numbers of people; everyone should be offered an HIV test. However, patients must still retain the right to know they are being tested and must not be tested without their consent.
In addition to finding new ways to expand HIV testing to reach all Americans, we must begin to recognize the interconnectedness between access to treatment and reduced HIV transmission. There is little point in testing someone if no treatment options are available. Several studies also suggest that effective medical treatment for HIV, whereby an individual’s viral load is reduced, significantly reduces the chance of transmitting the virus to somebody else. Two studies done in Switzerland and Thailand respectively concluded that HIV therapy alone can reduce HIV viral load to a level where it can’t be transmitted through sexual contact if certain other conditions are also met. Many in the community remain skeptical of these conclusions and continue to recommend using condoms consistently and correctly to reduce risk. But the relationship between effectively treating HIV and reducing the risk of transmission cannot be overlooked and should still be studied.
However, as the debate over universal health insurance demonstrates, guaranteed access to medical care does not exist in the United States. Wide disparities in health care access exist by both geography and social status. It was the lack of access to HIV care in many parts of the country that led lawmakers to introduce the Early Treatment for HIV Act (ETHA) (S. 860 and H.R. 3326) in Congress. As we go to press, the bill remains deadlocked in the political process. ETHA would give states the option to amend their Medicaid eligibility to extend health care and treatment access to low-income, pre-disabled individuals with HIV. At the same time, the CDC and Health Resources and Services Administration (HRSA) report that 25 to 32 percent of individuals newly diagnosed HIV positive have no way to pay for HIV care and treatment.3
At the congressional hearing, NAPWA’s president and CEO Frank Oldham Jr. said, “It needs to be stated unequivocally that people living with HIV/AIDS (PLWHA) are partners to achieving HIV prevention goals, but policies and laws that perpetuate stigma and discrimination and/or threaten confidentiality hurt efforts to engage PLWHA in prevention activities. Full and comprehensive access to HIV care and treatment as well as effective structural and biomedical prevention strategies must be included in our domestic response to HIV.” Oldham further said that success would only come with the support of broad social marketing campaigns focused on HIV/AIDS. Such marketing campaigns, he said, would depict people openly living with HIV/AIDS; they would discourage ignorance and misinformation about those who are living with HIV/AIDS and would thus fight AIDS-related stigma.
In light of this information, the AIDS community has an obligation to demand more research to understand the role of HIV diagnosis, care and treatment in the battle against HIV/AIDS. Our priorities must be to encourage people to get tested for HIV and then to provide them with health care, treatment and support if they test positive. More evidence continues to emerge to show that this will slow the spread of HIV and save lives.
1. See CDC Testimony Before the Oversight and Government Reform Committee. United States House of Representatives. http://oversight.house.gov/documents/20080916101852.pdf
2. See CDC Testimony Before the Oversight and Government Reform Committee. United States House of Representatives. http://oversight.house.gov/documents/20080916115223.pdf
3. Julie Gerberding and Elizabeth Duke. Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) Responses to the December 20, 2007, Letter From Representative Henry A. Waxman, Chairman, Committee on Oversight and Government Reform. September 9, 2008.
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