CDC says HIV prevention progress in US has stalled

Carlos del Rio, MD, FIDSA

The fact that, since 2013, we have not seen a decrease [in new HIV infections] is very concerning because in 2012, we had the approval of pre-exposure prophylaxis (PrEP), so the lack of decrease in new infections could be a result of the poor role out of PrEP. We are also not doing a good job keeping people engaged in care and, as a result, in the number of people virally suppressed. The percent of people living with HIV who are virally suppressed has not changed that much; it is still around 40%, and obviously what we are seeing is ongoing HIV transmission, and when you have ongoing HIV transmission, new infections do not go down. It simply shows that what is being done is not having an effect anymore, and this obviously relates to the current initiative that the president announced in the State of the Union address. You have to realize that to get a 75% reduction in new infections in 5 years and a 90% reduction in 10 years, you are talking about having to do way more than what we are currently doing. It is not just doing more of what we are currently doing; it is really doing something much more impactful.

We must implement PrEP, which has been grossly underused. Where it is mostly used is among men who are white, whereas the epidemic primarily affects blacks and Hispanics. We really need to scale up and make PrEP available to black men and to women. PrEP scale-up and, really, PrEP implementation and availability are huge steps. The second big step we must take is to find people who are infected, either who do not know they are infected or, more importantly, who know they are infected but have fallen out of care. We have to get them back into care. The math we have done here in Georgia suggests there are about 8,000 people out of care, and quite frankly, if you were to tell me today we are going to get all those 8,000 people into care, I would not know where to put them because the care sites are already saturated. We need to maintain perspective that there is a need to increase our capacity to care for people who have HIV and that a clinical care setting is grossly inadequate. The final issue is that we cannot forget social determinants of health. This epidemic is occurring among people who are poor; it primary impacts people who live in unstable housing, who have food insecurity, who lack education and jobs. If we do not address those issues, we are not addressing the root of the problem, and therefore, we will continue seeing an epidemic in the U.S.

Although the data reflect the status of HIV across the nation, I think we need to be careful and realize that HIV in the U.S. is not one epidemic but multiple micro-epidemics. The epidemic in Atlanta is very different from the epidemic in San Francisco or the epidemic in Seattle. Therefore, what worked in Seattle may not work in Atlanta. Local epidemics need local responses.