Update on HIV Prevention Techniques

Orlando—The incidence of HIV has been relatively stable in recent years, and therapeutic developments have prolonged life for people with the virus. Still, with 1.2 million people in the United States having HIV and 50,000 new infections occurring each year, healthcare professionals, pharmaceutical companies, and the government are pouring resources into finding ways to improve patients’ health.

Bernard M. Branson, MD, from the division of HIV/AIDS prevention at the Centers for Disease Control and Prevention (CDC), provided attendees at the Spring Managed Care Forum with an update on the disease during a session titled HIV–High Impact Prevention.

Dr. Branson said the incidence of HIV is increasing at the highest rate in African Americans. In 2009, the most recent data available, African Americans accounted for 44% of people with HIV in the United States, more than any other ethnic group. Whites accounted for 32% of cases, while Hispanics/Latinos accounted for 20%.

The estimated rates for new HIV infections in 2009 were 69.9 in 100,000 for African Americans compared with 26.4 in 100,000 for Hispanics, 14 in 100,000 for American Indians/Alaska natives, 9.1 in 100,000 for whites, and 8.3 in 100,000 for Asians. The estimated rates for new HIV infections were 19 in 100,000 for all people, 29.8 per in 100,000 men, and 8.6 per in 100,000 women.

“We’re seeing an [HIV] epidemic that is increasingly affecting minorities in the United States,” Dr. Branson said.

In July 2010, the White House released the National HIV/AIDS Strategy that, according to the government, is the first comprehensive plan to address the disease and set goals to be achieved by 2015. Among the goals are reducing the number of new HIV infections by 25% per year and the annual transmission rate by 30% while increasing the percentage of people with HIV who are aware of their infection from the current 79% to 90%. In addition, they want 85% of patients to receive care within 3 months of diagnosis and hope to increase by 20% the proportion of HIV-diagnosed gay, bisexual, African American or Hispanic individuals who have undetectable viral load.

Dr. Branson also discussed the CDC Division of HIV/AIDS Prevention’s strategic plan for 2011 through 2015. The plan includes numerous goals, including increasing early diagnosis of HIV by 25%, reducing the proportion of gay or bisexual men who have unprotected intercourse by 25%, and decreasing the proportion of injection drug users who report risky sexual behavior or using drugs by 25%. Dr. Branson said that reducing HIV incidence by 25% in the next 10 years would save 62,000 infections and $23 billion, while reducing the incidence by 25% in the next 5 years would save 109,000 infections and $42 billion.

As of 2010, 21% of people who had HIV were undiagnosed, according to Dr. Branson, who added that studies have shown that people substantially reduce high-risk sexual behavior when they become aware they are HIV positive.

Dr. Branson said that after diagnosis, people with HIV could live an additional 35 years if they undergo antiretroviral therapy (ART). He cited a 2006 study that found patients with HIV who received ART had an average per-person survival gain of 160 months compared with approximately 100 months for patients with relapsed non-Hodgkin’s lymphoma who underwent a bone marrow transplant, 30 months for patients with breast cancer who had adjuvant chemotherapy, and 5 months for patients with non–small-cell lung cancer who underwent chemotherapy.

“[ART] provides substantially more effectiveness than these other treatments,” Dr. Branson said.

To further demonstrate the effectiveness of ART, Dr. Branson cited an article from the New England Journal of Medicine [2011;365(8):493-505] that early ART therapy reduced the risk of HIV transmission by 96% compared with delayed therapy. The study looked at patients with HIV and CD4 counts between 350 and 550 cells per cubic millimeter who were in a stable sexual relationship with an uninfected partner. The National Institute of Allergy and Infectious Diseases funded the multicontinent, randomized, controlled study, which included 97% heterosexual couples.

“This was huge news,” Dr. Branson said.

In December, Science magazine chose the journal article as its “Breakthrough of the Year” for 2011. The editors noted that “in combination with other promising clinical trials, the results have galvanized efforts to end the world’s AIDS epidemic in a way that would have been inconceivable even a year ago.”

Dr. Branson also mentioned guidelines from the US Department of Health and Human Services for using antiretroviral agents. Although it is not known at what CD4 count it is best to initiate ART, he said it is recommended for all HIV-infected individuals, particularly for people with CD4 counts <350 cells/µL who are at risk of transmitting HIV to sexual partners.

There are many benefits of early ART therapy, according to Dr. Branson. He said untreated HIV might be associated with developing AIDS, and initiating ART therapy could also prevent HIV-related end organ damage.

Of the available ART therapies, Dr. Branson said the preferred option for most patients would be a combination of non-nucleoside reverse-transcriptase inhibitors, protease inhibitors, or integrase inhibitors plus 2 nucleoside reverse-transcriptase inhibitors. He added that fusion inhibitors and CCR5 receptor antagonists are not recommended for initial ART therapy, although he warned that there are few clinical end points to guide the decisions.

Dr. Branson cited clinical studies that showed patients who took ART maintained virologic suppression for at least 3 to 7 years after initiating therapy. He said appropriate initial ART regimens should suppress HIV indefinitely if patients have adequate adherence. If there is a failure associated with ART therapy, Dr. Branson suggested changing the therapy to reduce the pill burden, reduce dosing frequency, enhance tolerability, and decrease food and fluid requirements. The goals are improving quality of life and ART adherence while avoiding toxicities and reducing the risk of virologic failure.

If the HIV testing guidelines from the CDC were followed, Dr. Branson estimated there could be a 7% reduction in the estimated 1.2 million new infections in the next 20 years. When combined with expanded ART therapy, there could be a 17% reduction in new infections during that same time period, resulting in a savings of  $21,580 per quality-adjusted life year.

Other effective ways to reduce HIV include interventions focused on changing sexual behavior, which Dr. Branson said reduced unprotected sex by 43% and acquisition of sexually transmitted diseases by 80%. In addition, studies have shown that condom use is associated with an 80% to 90% reduction in HIV acquisition, according to Dr. Branson.