CROI 2019: Research and a moral obligation add up to a plan to end U.S. HIV incidence

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Science Speaks is in Seattle this week covering breaking news in HIV research, policies and plans at CROI 2019 March 4-7.

SEATTLE – Over the last decade, the evidence had continued to mount. From HPTN 052 to Partners 2 that HIV suppressed to undetectable levels is not transmitted, from the first results of antiretroviral drugs used for pre-exposure protection from the virus, to guidelines saying all people with high risks should be offered that option.

Theoretically, in a perfect world, if we put everyone living with HIV on therapy, everyone at high risk on PrEP, we could end the epidemic now, Dr. Anthony Fauci told an opening night audience here Monday. But, he added, we don’t live in a perfect world.

So why now, fresh from a 35-day shutdown of government agencies, when the world of policy and health program planning might seem, if anything, even less perfect than usual, had the time arrived to use what is known about stopping HIV transmissions, to set the goal of doing so across America within the next 10 years?

NIAID Director Dr. Anthony Fauci at a pre-plenary press conference Monday.

The National Institute of Allergy and Infectious Diseases director had flown in from Washington, DC that morning. When he was done talking he would head back to DC on a night flight, because he’s set to speak at a Senate hearing on measles today. But in between, he wanted to explain the plan announced in the Feb. 5 State of the Union address to “end HIV as we know it,” in the United States. He had explained the basics in a JAMA article two days after the announcement, and he now he wanted to answer the questions it had prompted.

The first is money. What the funding will be, set to be announced in the White House budget proposal later this month, he is not at liberty to say. But he contends with adamant certainty that the funding for the plan would not come at the expense of existing programs and services, including international HIV responses. And he added, the agencies involved — the U.S. Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Indian Health Service, the NIH, the Substance Abuse and Mental Health Services Administration, will work in unprecedented collaboration.

Why now? We actually do know more now, Dr. Fauci said, with recently analyzed data showing that of 3007 counties nationwide, half of all new HIV infections occur in just 48 of them, as well as the District of Columbia, and Puerto Rico. The opportunity for focus that offers he said, adds to the long known demographic disparities of America’s HIV epidemic — with its disproportionate and neglected impacts on African American and Latino gay men and on African American women, on young adults, on transgender women. 

Stigma, fueled by laws and policies — criminalizing people living with HIV, discriminating against gay and transgender people, keeping critical health services out of reach for people with substance use disorders, do play a role in the disproportionate burden faced by those communities, Dr. Fauci acknowledged. So why now?

Because it can be done, using strategies also long-known, to reach marginalized individuals and communities where they are — strategies used worldwide, and, as another opening talk highlighted, some that have provided the backbone of successes against HIV in Thailand.

“We’ve run out of excuses,” Dr. Fauci said, noting that he wrote an editorial to that effect three years ago.

“This is a moral obligation to make this happen,” Dr. Fauci said. “There’s no guarantee, but we’re certainly going to give it a try.”

 

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