This Week in HIV Research: Do As We Say, Not As We Do
We’ve long had a roadmap for eliminating HIV. It’s pretty simple, on paper: Test everyone. Treat everyone who tests positive. Remove obstacles to care that prevent those two things from happening. Boom. Virus solved.
Heck, we’ve even had guidelines in the books for many years intended to spur us toward those goals: universal, opt-out HIV testing guidelines; aggressive antiretroviral therapy recommendations; test-and-treat protocols. We talk the talk. But walking the walk? Not so much.
While our team also focuses on scientific coverage of the 23rd International AIDS Conference this week—when you’re done here, be sure to take a look at the AIDS 2020 news we’ve posted thus far!—our selected This Week in HIV Research studies this time around look at some recently published findings that prod at the persistent disparity that exists between what we know we ought to do and what we actually do.
This week’s research suggests that:
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U.S. guidelines have called for routine HIV testing in health care for well over a decade, but actual testing rates in ambulatory care settings remain woefully low.
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We know that sexually transmitted infections (STIs) are very much worth watching out for among people on HIV pre-exposure prophylaxis (PrEP), but we’re likely not testing PrEP users for STIs nearly often enough.
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Eight years after PrEP’s U.S. approval and six years after the first national guidelines were introduced regarding its use, uptake remains low among many key demographics, especially Black communities.
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We’re well aware of the potential benefits of opioid agonist therapy for people who inject drugs, as well as the challenges of hepatitis C testing and care among these folks—and we can be doing more to integrate solutions.
Let’s talk more about the walking we need to do. To beat HIV, you have to follow the science!
HIV Testing Opportunities Are Usually Missed in Ambulatory Care Settings
Many, if not most, opportunities for HIV testing during ambulatory care visits are missed in the U.S., a study published in Morbidity and Mortality Weekly Report showed.
The findings are based on data from two large national surveys spanning several years (2009 to 2016 for one, 2009 to 2017 for the other) and involving a total of 516 million physician’s office visits, 87 million emergency department visits, and 37 million community health center visits. Researchers determined that the proportion of ambulatory care visits during which an HIV test was ordered rose over time at community health centers and emergency departments, but did not improve at physician’s offices.
Despite increased testing in some settings, overall rates still topped out at just 2.65% for visits to community health centers. Yet by comparison to other settings, that percentage was high: In emergency departments and at doctor’s offices, fewer than 1% of encounters with non-pregnant people were associated with an HIV test. Opt-out HIV testing has been recommended as a part of routine health care in the U.S. since 2006, with annual testing recommended for high-risk individuals.
Testing was found to be more likely during preventive rather than acute care visits, as well as in cases where blood was already being drawn for another reason.
These missed opportunities for HIV testing are especially problematic for populations disproportionately affected by the virus, such as young Black and Latino men or people who inject drugs, study authors noted. They recommended decision support tools in the electronic health record to prompt the physician and routine opt-out testing in emergency departments and similar settings.
“To end the HIV epidemic, testing of patients seeking care in ambulatory health care settings should be leveraged to increase the percentage of diagnosed infections and reduce HIV transmission,” the authors concluded.
Screen PrEP Users for STIs More Often, Researchers Recommend
Quarterly HIV testing is already standard for people taking pre-exposure prophylaxis (PrEP) in the U.S., but screening for sexually transmitted infections is often not as frequent—and that may be impairing our ability to quickly diagnose and treat infections, a new study suggests. The study found that 51% percent of 557 men who have sex with men (MSM) and transgender women participating in the US PrEP Demonstration Project had an STI during follow-up, researchers reported in AIDS.
If those individuals had been screened for such infections quarterly instead of biannually, 34% of gonorrhea, 40% of chlamydia and 20% of syphilis cases could have been diagnosed up to three months earlier, the researchers determined. The sooner an STI is diagnosed, the sooner treatment can start, which also can reduce onward transmission, especially when combined with partner services.
Study authors proposed adding a standing order for a syphilis test when blood is drawn for the person’s quarterly HIV test. Self-collected swabs during PrEP visits, in addition to urine collection, could be used to test for extragenital gonorrhea. “Quarterly STI screening among MSM on PrEP could prevent a substantial number of partners from being exposed to asymptomatic STIs, and decrease transmission,” they concluded.
U.S. PrEP Uptake Rising Among Some, But Disparities Persist
While the likelihood of having used PrEP rose 34% per year since comprehensive U.S. PrEP guidelines were first released in 2014, use of biomedical HIV prevention is still quite uneven across demographic groups, a meta-analysis of 95 studies that was published in Journal of Acquired Immune Deficiency Syndromes found.
The review spanned studies published between 2004 and 2017, and focused in particular on the 2015-to-2017 period. Within that span, MSM were determined to be more than twice as likely as non-MSM to use PrEP, and nearly four times as likely as people who inject drugs. PrEP usage from 2015 to 2017 ranged from a high of 14% among MSM, 12% among Latinx people, and 11% among transgender women to a low of 7% among youth and 4% among people who inject drugs (PWID).
Researchers called for additional studies to better understand barriers to PrEP uptake in PWID. In addition, since the most common PrEP agent, tenofovir disoproxil fumarate/emtricitabine (Truvada), was not approved until May 2018 for people below the age of 18, follow-up studies among youths are needed, they added.
The data also point to geographic disparities in PrEP availability, with PrEP usage in the U.S. South from 2015 to 2017 at around 10% despite the fact that half of new HIV diagnoses in the country occur in that region. PrEP usage also did not rise significantly in the southern U.S. during that time period, even though it improved significantly among Black people, another heavily HIV-affected community.
Notably, none of the studies that were analyzed focused on Black women, who in 2017 accounted for 59% of new HIV diagnoses among women. Future research must include this demographic, study authors wrote.
Integrated Opioid Care for PWID Can Fill Gaps in Hep C Care Cascade
Among people who inject drugs, opioid agonist therapy (OAT) can serve as a gateway to hepatitis C (HCV) testing and treatment, a meta-analysis of 22 studies (most conducted in Australia) published in Clinical Infectious Diseases found. (Three of the 15 study authors reported grants from Indivior, a manufacturer of opioid addiction treatment drugs.)
The analysis found that the odds of receiving interventions across the HCV testing and treatment cascade were higher among injection drug users who received opioid agonist therapy compared to those who did not. Among people who were currently on OAT or who had recently received it compared to people who did not receive OAT, overall odds ratios were 1.8 for receipt of HCV antibody testing, 1.8 for HCV RNA testing among people whose antibody test is positive, and 1.5 for initiation of direct-acting antivirals among people who test positive for HCV RNA.
By contrast, there was not a statistically significant difference seen in the impact of OAT on a person’s odds for completing direct-acting antiviral therapy and achieving sustained viral suppression.
Study authors called for integrating OAT and HCV care for people who inject drugs. But given the limited access to opioid treatment across the world, much more needs to be done to achieve that integration, argued Sarah Kattakuzhy, M.D., and Elana Rosenthal, M.D., of the University of Maryland School of Medicine in a related commentary. HCV care must be coupled with other services PWID access, such as syringe service programs, and also provided in prisons and jails, they asserted.
While the current COVID-19 pandemic may disproportionately impact PWID due to reduced access to services and sterile supplies, as well as overburdened emergency departments, it also provides an opportunity for creating an integrated, stigma-free care system for PWID that goes beyond HCV treatment, the two commentary authors concluded.