Because current levels of HIV spending are unsustainable, HIV prevention and intervention efforts must become highly targeted in order to maximize their impact. This was the theme of many presentations at the 10th International Conference on HIV Treatment and Prevention Adherence. The conference, held June 28 to 30 in Miami, Florida, was jointly provided by the International Association of Providers of AIDS Care (IAPAC) and the Postgraduate Institute for Medicine (PIM).
Despite advances in controlling the epidemic, certain populations continue to experience high rates of infection, among them injection drug users in Eastern Europe, men who have sex with men (MSM) worldwide, transgender populations and young women in sub-Saharan Africa. According to global data from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), there are 40,385 new infections weekly, among them over 4,600 in babies and 7,000 in young women. The epidemic will continue to balloon unless the current window of opportunity is strategically utilized to dampen new infections, all in an effort to meet the UNAIDS 90-90-90 target by 2020: 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving treatment will have viral suppression.
This geospatial prioritization focuses on localities that are most at risk. PEPFAR's Ambassador Deborah Birx, M.D., highlighted this in her keynote address, stating that efforts and resources to end HIV must be focused by doing the "right thing at the right place at the right time." Practice-based evidence must be utilized to complement research-based evidence. As noted in PEPFAR 3.0 Controlling the Epidemic, efforts need to pivot "to a data-driven approach that strategically targets geographic areas and populations where we can achieve the most impact for our investments."
Utilizing HIV Impact Assessments, these international efforts will include such "right things" as improving site monitoring and program quality while scaling up core interventions such as antiretroviral therapy, condoms, prevention of mother-to-child transmission and efforts to combat tuberculosis. The "right places" will be identified utilizing multiple data sources to pinpoint geographic areas with the highest HIV burden at sub-national levels. The "right time" is, simply put, now. PEPFAR has outlined short-term objectives such as achieving efficient and effective control of the epidemic in five to 10 countries by 2016, all with an eye toward the 2020 goals.
In addition to PEPFAR, the U.S. Centers for Disease Control and Prevention (CDC) and the Global Fund have also called for new funding models targeting communities that are most affected. Several projects utilizing this strategy were highlighted at the IAPAC/PIM conference. Each called for collaboration and efficiency in light of funding uncertainties such as the Global Fund's cancelling of new funding rounds several years ago, and a proposed 18% reduction in U.S. government contributions to the Global Fund in 2015.
One such effort using data-driven interventions is IAPAC's own Fast-Track Cities Initiative, which launched in Paris on World AIDS Day in 2014. This program leverages existing HIV programs and resources in more than 200 high-incidence cities to strengthen the response to HIV in order to achieve the 90-90-90 target as well as zero discrimination, the latter goal related to stigma having been described as the most challenging objective of all.
LINCS (Linkage, Integration, Navigation and Comprehensive Services) in San Francisco is another effort. The local HIV registry is utilized to create a not in care (NIC) list comprised of persons who have been out of care for more than six months, as well as those who did not link to care within 90 days of diagnosis. The LINCS program utilizes a strengths-based case management model and has been very effective in re-engaging patients. Most individuals were receptive to this outreach (only 2% refused) and received tailored services ranging from reminders to being escorted to appointments. Those who were never linked to care were given warm handoffs (referrals and introductions of the patient from provider to provider in real time) to case management and housing services. Among enrollees, viral suppression doubled within 12 months and 74% of patients were successfully retained in care.
New York City has a similar program using the HIV registry, which incorporates other vital statistics such as death records, laboratory results, and records from both health departments and community providers. Data from this program indicated fluctuating efficacy in suppressing viral loads, with men being more virally suppressed than women and Hispanics more consistently returning to care and maintaining suppressed viral loads. Retention in care improved, especially in the first year after contact and among those aged 40 or older.
The CDC has a toolkit called Data to Care (D2C), which promotes collaboration among providers and incorporates a variety of interventions that are dependent on individual and local need. Some people, for example, may simply require reminders of appointments while others, such as those with co-occurring mental health concerns, may need more proactive involvement.
While these are not new public health strategies they are being utilized more consistently for HIV, and not without concern. Catherine Hanssens of the Center for HIV Law and Policy stated that the expectation of privacy between individual HIV testing data, surveillance and treatment records is being betrayed by these efforts. While each program has redundant procedures to protect confidential patient information, there is always a risk when boundaries for health care data are relaxed.
Despite these concerns, and in light of limited funds and an uncontrolled epidemic among certain populations, the use of data to identify both individuals who are out of care and to match limited resources with high HIV burden locales is proving an effective means by which to stop the epidemic during this shrinking window of opportunity.