This reflection piece details the many challenges and opportunities COVID-19 has brought to the HIV/STD prevention field, particularly in the southern United States, and showcases the innovative approaches sexual health providers implemented to further prevent service disruption.
While the COVID-19 pandemic is still ongoing, this document looks at what the sexual health workforce has been through, and continue to go through, navigating ending an HIV epidemic while in a global pandemic.
Sexually transmitted infections (STIs) impose billions of dollars in medical costs in the U.S., but STI prevention and control is chronically underfunded, stigmatized, and siloed from efforts to promote overall health and well-being, says a new report from the National Academies of Sciences, Engineering, and Medicine. The report calls for modernizing national STI surveillance and monitoring systems, bolstering the STI workforce, developing and scaling up structural and behavioral interventions, and accelerating the development of vaccines, diagnostics, and therapeutics. Taking these strategic actions would also better position the U.S. to respond to COVID-19, HIV/AIDS, and future infectious disease outbreaks, the report says.
Image courtesy of Charles Deluvio
The prevention and control of STIs requires a more holistic approach that promotes sexual health and expands access to comprehensive prevention and treatment services — rather than focusing on individual behaviors or blaming people who acquire STIs, says Sexually Transmitted Infections: Adopting a Sexual Health Paradigm.
Despite the economic burden and alarming increase of STI rates over the last 20 years, the Centers for Disease Control and Prevention’s STI funding has remained flat. Although HIV is an ongoing and highly significant concern, the mandate of the committee that wrote the report was to focus its recommendations on STIs other than HIV, due to increasing rates of chlamydia, gonorrhea, and syphilis. However, the report discusses the interplay between HIV and other STIs, and ways HIV and STI services can collaborate or integrate their prevention, care, and research efforts.
As 2020 draws to a close, we asked David Alain Wohl, M.D., a professor of medicine in the Division of Infectious Diseases at the University of North Carolina and a highly respected HIV clinician-researcher, to take stock of the year’s most momentous research developments and other critical events. In this exclusive series of articles, Wohl calls attention to 10 such developments that have tremendous short-term implications for our day-to-day efforts to improve HIV prevention, treatment, patient care, and policy in the U.S., and analyzes each development with his trademark wit and clinical savvy.
“Looking for something we can rely on. There’s got to be something better out there,” Tina Turner sings in her 1980s pop hit “We Don’t Need Another Hero.” That song jumps into my head when I think about new HIV therapies, but in my mind, it’s framed as a question: Do we need another hero?
For those with few antiretroviral options, who are downing multiple pills to keep multidrug-resistant virus from replicating, the answer would be yes: We do need another antiretroviral hero.
Fortunately, the number of people living with HIV who are heavily treatment experienced and have few remaining antiretroviral options is fairly small. Among over 27,000 HIV-positive people in the U.S. who were treatment experienced and in care at one of the HIV clinics contributing to the U.S. Centers of AIDS Research Network of Integrated Clinical Systems (CNICS) cohort from 2000 to 2017, just 916 had limited treatment options (LTO)—a status defined as having two or fewer available antiretroviral classes, as well as two or fewer active drugs per class as determined by resistance testing. After 2007, the proportion of people with LTO fell; it has since remained less than 1% of the cohort’s antiretroviral experienced patients.
For more than 30 years, Gaétan Dugas was blamed for bringing the AIDS epidemic to the United States. A French-Canadian who died in 1984, Dugas was thought to have carried the disease to America and transmitted it to scores of sexual partners while working as a flight attendant.
But this week, scientists finally cleared the name of the man who, in the history of the AIDS epidemic, came to be known as “Patient Zero.”
In a study published in the journal Nature, the researchers found that blood sampled from Dugas in 1983 contained the same strain of HIV that was infecting men in New York City as early as 1971 — three years before he arrived in the U.S. as an employee for Air Canada.
In 2018, 37,968 people received an HIV diagnosis in the United States (US) and dependent areas. From 2014 to 2018, HIV diagnoses decreased 7% among adults and adolescents. However, annual diagnoses have increased among some groups.
Gay and bisexual men are the population most affected by HIV, with Black/African American, Hispanic/Latino gay and bi men having the highest rates of new infections.
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The number of new HIV diagnoses was highest among people aged 25 to 34.
While current antiretroviral treatments for HIV are highly effective, data has shown that people living with HIV appear to experience accelerated aging and have shorter lifespans—by up to five to 10 years—compared to people without HIV. These outcomes have been associated with chronic inflammation, which could lead to the earlier onset of age-associated diseases, such as atherosclerosis, cancers, or neurocognitive decline.
A new study led by researchers at Boston Medical Center examined what factors could be contributing to this inflammation, and they identified the inability to control HIV RNA production from existing HIV DNA as a potential key driver of inflammation. Published in The Journal of Infectious Diseases, the results underscore the need to develop new treatments targeting the persistent inflammation in people living with HIV in order to improve outcomes.
In a 2018 survey of men who have sex with men taking pre-exposure prophylaxis (PrEP) in three U.S. cities, about 10% reported sharing their medication with others.
This finding raises concerns that gay, bisexual and other men who have sex with men (MSM) may be accessing PrEP without receiving the medical monitoring that is supposed to go hand in hand with taking Truvada (tenofovir disoproxil fumarate/emtricitabine) or Descovy (tenofovir alafenamide/ emtricitabine) for HIV prevention—namely, HIV tests every three months and routine screening for sexually transmitted infections and kidney function.
As described in JAMA Network Open, Gordon Mansergh, PhD, a senior behavioral scientist in the Centers for Disease Control and Prevention’s Division of HIV and AIDS Prevention, conducted a cross-sectional analysis of responses from a 2018 smartphone-based survey of 755 HIV-negative MSM living in Detroit, Atlanta and New York.
Initial data from a large NIH-supported clinical trial offer a detailed look at the health status of people aging with HIV around the world. With 7,770 participants enrolled in 12 countries across five continents, the Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE ) is evaluating the ability of a statin medication, pitavastatin, to reduce the risk of heart disease among people with HIV. By leveraging data collected from this diverse group of study participants, researchers also are learning more about the long-term health effects of HIV. They report their initial findings in an August supplement for The Journal of Infectious Diseases.
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For women, accelerated reproductive aging—a natural process that eventually leads to menopause—may heighten risk for heart disease and stroke. Among women with HIV in the REPRIEVE study, more advanced reproductive age was associated with two risk factors for cardiovascular disease: high waist circumference and high blood levels of hemoglobin. Women living in sub-Saharan Africa or Latin America and the Caribbean were more likely to experience accelerated reproductive aging than those living in high-income countries.
The initial REPRIEVE findings also provide insight into the relationship between HIV and heart disease among transgender people, about which little is known. Transgender people are disproportionately affected by HIV, and studies have suggested that hormone use as part of gender-affirming therapy may increase cardiovascular disease risk. By collecting data on gender identity and use of gender-affirming therapy, the REPRIEVE investigators aim to address this knowledge gap. Notably, their initial analysis revealed that high waist circumference was more common among transgender women, particularly those who were receiving gender-affirming therapy.
Bruce W. Furness, M.D., M.P.H., from the U.S. Centers for Disease Control and Prevention in Atlanta, and colleagues developed and evaluated a quality improvement initiative (Transforming Primary Care for LGBT People) to enhance the capacity of 10 federally qualified health centers (FQHCs; 123 clinical sites in nine states) to provide culturally affirming care.
The researchers found that FQHCs reported increases in culturally affirming practices, including collecting patient pronoun information (42.9 percent increase) and identifying LGBT patient liaisons (300.0 percent increase). Based on sexual orientation and gender identity (SOGI) from electronic health records among nine FQHCs, SOGI documentation increased from 13.5 to 50.8 percent of patients. Screening of LGBT patients increased from 22.3 to 34.6 percent for syphilis, from 25.3 to 44.1 percent for chlamydia and gonorrhea, and from 14.8 to 30.5 percent for HIV among the eight FQHCs reporting the number of LGBT patients.
“FQHCs participating in this initiative reported improved capacity to provide culturally affirming care and targeted screening for LGBT patients,” the authors write.
[On July 2, 2020], the U.S. Food and Drug Administration approved Rukobia (fostemsavir), a new type of antiretroviral medication for adults living with HIV who have tried multiple HIV medications and whose HIV infection cannot be successfully treated with other therapies because of resistance, intolerance or safety considerations.
“This approval marks a new class of antiretroviral medications that may benefit patients who have run out of HIV treatment options,” said Jeff Murray, M.D., deputy director of the Division of Antivirals in the FDA’s Center for Drug Evaluation and Research. “The availability of new classes of antiretroviral drugs is critical for heavily treatment-experienced patients living with multidrug resistant HIV infection—helping people living with hard-to-treat HIV who are at greater risk for HIV-related complications, to potentially live longer, healthier lives.”
This reflection piece details the many challenges and opportunities COVID-19 has brought to the HIV/STD prevention field, particularly in the southern United States, and showcases the innovative approaches sexual health providers implemented to further prevent service disruption.
