SEATTLE -- The much-discussed plan to end the HIV epidemic in the U.S. through targeted treatment and prevention outreach is the first time an accelerated effort has been undertaken by multiple Health and Human Services agencies to tackle this problem, speakers said at a special session here.
In a talk at the opening plenary session of the Conference on Retroviruses and Opportunistic Infections, Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), outlined the plan previewed by President Trump in his State of the Union address in February to reduce the number of new HIV infections in the U.S. by 75% in 5 years, and by 90% in 10 years.
"We have and the Global Fund, but we've been talking for 10 years about the feasibility of ending the epidemic [in the U.S.]. This is a full-court press," Fauci told MedPage Today in a pre-conference interview.
This "full-court press" involves the CDC and the Health Resources & Service Administration (HRSA), along with the NIH, the Indian Health Service, and Adm. Brett Giroir, MD, assistant secretary of HHS. It came together about a year ago with the appointment of Robert Redfield, MD, as director of the CDC.
"I've known Bob Redfield for 37 years, and we got together and said 'Maybe if we put together a proposal, we could bring it to HHS and get a plan moving,'" Fauci explained to MedPage Today.
At the presentation, Fauci said that after the five departments developed the plan, it was submitted to HHS Secretary Alex Azar. Fauci commented that Azar is "a very old and dear friend," and the two helped put together the PEPFAR program during the George W. Bush administration.
"Azar brought this to the president and said, 'Put it in the State of the Union address to give it momentum and I will put in the budget what we need to get this done,'" Fauci said.
The basis of the plan is simple, though there are several moving parts. Fauci described it as "treatment as prevention plus pre-exposure prophylaxis (PrEP)." -- meaning diagnose and treat all HIV infected individuals as quickly as possible, and put those at high risk of acquiring HIV on PrEP to prevent them from becoming infected.
"This plan is not a basic or clinical research plan, but it is fundamentally an implementation plan," Fauci said.
He added that it is based on the results of several prominent studies in the field of HIV: the idea of "U equals U" (undetectable equals untransmittable), or a person with an undetectable viral load cannot transmit HIV to another person, and the 95% effectiveness of PrEP at preventing the new acquisition of HIV infections.
Specifics of the plan involve "demographic and geographic targeting" of HIV hotspots, and is based on successful efforts at reducing HIV incidence in larger areas of the country, such as San Francisco, New York, and Washington.
Fauci said that demographic disparity of new HIV infections is well-known -- about 44% of new infections are among African Americans, 60% are in men who have sex with men, and 75% are in young people. These would be "target populations" to focus efforts.
"Demographic [disparities] we knew about, but have an amazing geographic hot spot concentration," Fauci said at the presentation.
Indeed, over 50% of new HIV infections were concentrated in 48 U.S. counties (out of 3,007 counties), plus the District of Columbia and Puerto Rico, Fauci said. He added that there are seven mostly southern states with a "disproportionately high HIV incidence in rural areas."
The idea would be to improve both rates of viral suppression and portion of individuals at high risk for HIV infection on PrEP. Fauci cited HRSA's , with an almost 86% rate of viral suppression in people diagnosed with HIV compared to the 60% U.S. average. He also cited the 1.1 million people at high risk of acquiring HIV, despite only 260,000 people who are on PrEP. The goal would be to get a 90% rate of U.S. viral suppression, and 50% of high-risk people on PrEP, Fauci said.
This plan would mostly be enacted by the CDC and HRSA, with the former in conjunction with state and local health departments, and the NIH providing more of a supporting role. Fauci said the program's efforts would consist of "grassroots outreach" in the communities, especially at clinics that treat sexually transmitted diseases (STD).
"If someone comes to a STD clinic and doesn't have an HIV infection, they need to be put on PrEP," Fauci noted.
Immediate next steps for the program would be that the funds would be included in President Trump's budget, which he is expected to send to Congress in the next couple weeks. While the CDC and HRSA would be the main recipients of the new funds, NIH will "take money from other areas and supplement [the Centers for AIDS Research] across the country" to help support these efforts.
"Brett Giroir said there is no question that he was promised there would be new additional resources for this," Fauci said.
Primary Source
Conference on Retroviruses and Opportunistic Infections
Fauci A "Ending the HIV epidemic: A plan for the United States" CROI 2019.