Chapter 2: The Current Situation of HIV in the US

Moderator: Thank you, Dr Lopes. So, if HIV really is a unique animal, especially in terms of the populations it impacts, some of the challenges facing them, and the stigma that it engenders, what's our current situation? Dr Cohen, I'll turn to you. 

Dr Steve Cohen: Thanks, Eric. You know, as we take a deeper dive into the epidemiologic data, I think it demonstrates that the anticipated progress on reducing new HIV infections in the U.S. has unfortunately stalled. 

Take a look at this heat map, and what this is it outlines the rate of HIV by geography, darker colors demonstrate higher challenges, and we still see a large number of individuals living with HIV in 2022. This is especially prevalent in the South and in the Northeast, but there are localized pockets throughout the United States.  

In essence, we're simply not reaching the populations that are critical to ending this epidemic, and it is projected that without strategic intervention, as many as 400,000 more Americans will be newly diagnosed with HIV by 2032, and that's what we're really here to talk about today, how all of us can get involved in the effort to curb HIV transition and end the HIV epidemic. 

The Department of Health and Human Services recognized the urgency of HIV transmission rates not decreasing, and the need to take formal action, and in 2019, launched a new initiative titled Ending the HIV Epidemic, or EHE. As you can see, the goals of this initiative were to reduce new HIV infections by 75% by this year and at least 90% by 2030.  

The HIV EHE initiative has outlined 4 key strategies to achieve these goals, and six indicators which allow us to measure our progress associated with each of the strategies. The 4 most effective strategies are diagnosed, treat, prevent, and respond. Diagnose all individuals with HIV as soon as possible, treat people living with HIV rapidly and effectively, to obtain viral suppression, prevent new HIV transmissions through PrEP coverage, and respond quickly to potential HIV outbreaks. 

The six indicators talk about new diagnoses of HIV, the percentage of individuals who know their status, the linkage of medical care to a diagnosis of HIV, viral suppression, measured by viral counts which are essentially less than 200 copies, the percentage of individuals who are receiving PrEP coverage, in other words, the number of persons prescribed PrEP, divided by the estimated number of persons who have had a clear indication for PrEP, and finally, the estimated incidence of newly diagnosed and undiagnosed cases of HIV. 

I'd like to provide a few examples of why the indicators used to measure progress should matter to all of us. First off, knowledge status is absolutely critical to ending the epidemic. 

There is also a very large number that can be significantly reduced by strategies to increase the recommended frequency of HIV testing, thereby decreasing unknown transmission to a partner. In 2016, 80% of new HIV infections in the U.S. were transmitted from people living with HIV who had no knowledge of their status or had been diagnosed but were not receiving care, and it's critical that an individual newly diagnosed must be immediately linked to HIV medical care. It's a big challenge but think about the number of new infections that could have been prevented by testing followed by immediate linkage to treatment. 

Working together, we have the tools needed to end the HIV epidemic and meet the 75 and 90% reduction in new diagnoses goals, as I mentioned earlier. Pre-exposure prophylaxis, or PrEP, reduces the risk of acquiring HIV by up to 99%.  

It is a proven, cost-effective, and guideline-recommended cornerstone of the 2019 EHE plan, and the advances in antiviral therapy, or ART, allow people living with HIV to expect similar life expectancy as those without HIV, and when taking medicine as prescribed to reach undetectable levels of virus, they will not transmit the virus to their sexual partners. Linkage to medical care is good business, and I suspect most of you realize that members with HIV who are not receiving antiretroviral therapy incur higher utilization and claims costs. This was demonstrated in a 2020 study with the highest cost seen in HIV-associated conditions and infections, mental health disorders, and treatment for other comorbid conditions. Following a 2022 U.S. federal court ruling against requiring health insurers to cover PrEP under the ACA, in March 2023, researchers from Yale and Harvard published a brief report in Open Forum Infectious Disease sharing the potential consequences of this decision. A very conservative estimate identified that for every 10% decrease in PrEP coverage, this would result among U.S. men who have sex with men, the authors estimated resulting in 1,140 additional HIV infections in the following year. 

And we certainly continue to encourage our health plan partners to allow coverage of PrEP without obstacles.