Weekend Reads | A Hopeful New Era for HIV Care

by Kevin Schofield

This weekend's read is a compendium of facts and figures on the current state of the HIV epidemic, published by the Centers for Disease Control and Prevention (CDC), the U.S. government's primary public health agency.

The HIV virus, and the disease it causes that we commonly call AIDS, have been with us for over 40 years now. It's estimated that last year there were 39.9 million people living with HIV worldwide, 1.2 million of them in the United States. In 1983 and 1984, there were about 130,000 new infections per year in the U.S.; by 1991, that had dropped to about 50,000, and in 2022, there were 31,800. The CDC's goal is to reduce the annual number of new infections to 3,000 by 2030. That is an ambitious goal, but it is achievable. That is a remarkable statement, and turnaround, for a battle that has raged for four decades in which health care researchers and providers have repeatedly faced setbacks and disappointments.

When I was a young adult in the 1980s and 1990s, HIV was considered a death sentence. With no cure, no vaccine, limited treatments, and few methods to prevent transmission, being HIV positive guaranteed you would be stigmatized, shunned, and ultimately suffer a slow, unpleasant death. In a few corners of the world, this is still largely the case, though in many places, including here in the United States, things have improved in several important ways. While there is still no cure, there are antiviral treatments that can reduce an HIV-positive person's viral load to nearly undetectable levels and with ongoing treatment keep it there indefinitely, maintaining their health, extending their expected lifetime, and reducing the likelihood that they will pass on the virus to anyone else. Similarly, while there is no vaccine for HIV in the classic sense — one that would teach our body's immune system to fight off the virus if exposed to it — antivirals are now used as "pre-exposure prophylaxis," or "PrEP," to lower the chances of a person at high risk from becoming infected.

It took a long time to get here. HIV, much like the coronavirus that causes COVID-19, mutates very quickly, which is one of the reasons it has evaded efforts to create an effective vaccine against it. There have been many attempts at HIV vaccines, and to date, all have failed. Along the same lines, HIV evaded the earliest generations of antiviral treatments by mutating quickly, but ultimately, researchers landed upon a "cocktail" of antivirals that, if delivered together, provided a broad enough front that HIV couldn't wriggle around them (yet).

The "cocktail of antivirals" approach is the main approach used today, and for the moment, it remains effective, though it isn't without its problems. The most common HIV antiviral treatments and PrEP regimens involve regular (often daily) doses of pills. Many people, including those in vulnerable communities and people with substance abuse issues, may have trouble sustaining that kind of regular regimen, and if they can't keep it up, they lose some or all of the protection it provides. Fortunately, there is a new generation of antivirals now being used for PrEP that require far less work, such as an injection once every one or two months. And in a landmark study published just last month (that got a standing ovation when it was presented recently), an antiviral medicine injected once every six months to 2,000 high-risk women in Africa provided 100% protection from infection.

We can't overstate how important this milestone is. In many parts of the world, taking PrEP oral medications is not only a difficult burden but is stigmatizing in itself. Having a ready alternative where someone can get a shot just twice a year, in the privacy of a clinic, changes everything. To be clear, this new study needs to be repeated to validate the unheard-of 100% success rate, and production of the medicine will need to be scaled up. But when we look at the full arsenal of tools and treatments that we now have to combat HIV, we are in a very different place than we were just a few years ago:

• Antiviral treatments that can suppress viral load in an HIV-positive person, extending their health and life and reducing the likelihood that they will infect others;
• Highly effective PrEP regimens to protect uninfected persons that can be delivered easily, infrequently, and at a reasonable cost;
• Over-the-counter HIV tests that can be taken in the privacy and convenience of one's own home, providing instant data on whether someone has become infected.

In that context, the CDC's goal of reducing new HIV infections to 3,000 per year by 2030 looks very achievable. It will require resources and political will, but now we can clearly see the path to get from here to there.

The CDC's compendium of facts and figures on HIV provides us important guidance on where to focus efforts by showing us the key demographic and geographic trends driving ongoing infections. For instance, in the 31,800 new infections in 2022, about two-thirds were among men who reported having sexual contact with other men. Another 22% were through heterosexual contact, and 7% were among people who inject drugs.

Nearly half of the new cases were in "Deep South" states; only 14% were in the Northeast, despite the highly concentrated population in that region. The concentration of people with HIV is also higher in the Deep South (506.5 per 100,000 people).

The group of men who became infected through sexual contact with other men is disproportionately Black/African American and Hispanic/Latino. The same is true for the group of people who became infected through heterosexual contact.

Among the people who became infected through injecting drugs, Black/African American and Hispanic/Latino persons are still overrepresented, but not to the same extent.

Interestingly, the CDC found that 87% of HIV-positive people in the U.S. knew their HIV status, and nearly two-thirds of them were being treated to suppress the virus. The CDC's goal is to increase viral suppression to 95% by next year. And 72% of all people with HIV rated their overall health as good or better — another huge milestone that was practically unimaginable 20 years ago.

There is additional important discussion in the CDC's report on some of the other factors that people who are HIV positive deal with, including the level of stigma they experience, their access to mental health services, and their economic fragility. While there have certainly been improvements since the 1980s, we still don't universally treat HIV-positive people with the dignity, care, and support they deserve. It's important, too, to understand that we must take great care in applying the demographic data that the CDC has compiled to focus a response. Emphasizing specific communities that are highly impacted by HIV can too easily turn into further stigmatizing those communities if we don't approach the task with care, respect, empathy, and nuance.

That said, for a field of work that has experienced decades of failures and disappointments, it's encouraging to think we might have finally turned a corner, and there is genuine reason for optimism about our ability to end the HIV epidemic. We still don't have a cure, or a vaccine, but with the tools we now have in place, HIV is no longer a death sentence for those infected, and it appears that, with the right resources and effort, we can reduce new infections to a tiny fraction of their historical rates.

Fast Facts: HIV in the United States

Featured image via CREATISTA/Shutterstock.com.