Patrick Sullivan, PhD, a professor of epidemiology at Emory University in Atlanta, talks about a new drug to help stop the transmission of HIV as well as advocates for widespread testing for everyone.
Professor Sullivan: Well, I think we’re at a really exciting time in the efforts to end AIDS and to prevent the transmission of the HIV virus. We’re at a really exciting time in addressing the HIV epidemic in the United States because we now know that there are two highly effective ways to reduce transmission of HIV using antiretroviral medications.
Professor Sullivan So, one of those is through PREP or pre-exposure prophylaxis which is highly efficacious. We’re at a very exciting time in efforts to end the HIV epidemic in the United States and one of the reasons that it is such an exciting time is that we now have ways to reduce the risk or prevent transmission of the virus because of antiretroviral medications. And those two ways are one, for people who were living with HIV, we know when people are diagnosed they receive a prescription and take those medications that suppress viral load and that results in that person being unable to transmit the virus to another person. At the same time, some of those same antiretroviral drugs could be used for people who are not living with HIV to reduce the chance of acquiring HIV through sex. So, knowing that we now have tools both for people living with HIV – antiretrovirals improve health, prolong life, and effectively make it impossible for them to transmit HIV and for people who are at risk for HIV but HIV negative, there are drugs that can help reduce their chance of acquiring HIV. So, we know these two powerful tools. One thing that’s important to understand is that knowing your HIV status is the entry point to taking the right steps to protect your health, to improve your health whether you’re living with HIV or not. HIV testing is such a critical starting point to know your HIV status and know what the best next steps are for each person to protect their health and to prevent new transmissions of HIV.
Professor Sullivan Over a period of years, about one in five new HIV diagnoses is occurring among young people. And those are people aged 13 to 24 but importantly including teens. We also know that this youngest age group is the group that is most likely to be unaware of their HIV infection if they are infected. Almost half of the young people 13 to 24 who are living with HIV don’t know their status. So, HIV testing for young people is an incredibly important part of helping people protect their health and take medications if they need them to control the virus. At the same time, we know that young people, especially young men who have sex with men, are the largest group of diagnoses in young people. The young men who have sex with men are actually the least likely of all the age groups to have tested for HIV in the last year. So, just for perspective, CDC recommends that all Americans age 13 to 64 are tested for HIV at least once in their lifetime as part of routine medical care. But for men who have sex with men, that recommendation is to test more often—at least once a year for men who have sex with men. So, in light of that when my colleague, Travis Sanchez, did a survey with ten thousand men who have sex with men in the United States and asked, ‘have you been tested in the last year?’ That 13 to 24 age group was the smallest proportion of men who had been tested, only forty-five percent of them compared to over 70 percent of older men. So, we have this disconnect where young men who have sex with men especially are at high risk for HIV, CDC would say we’d like to see testing at least once a year, but less than half of those young men who have sex with men are getting that testing. It’s so critical not just to find out if one is living with HIV and if so, there are important steps to improve your health and to stay healthy, but testing is also the gateway to pre-exposure prophylaxis. So, if someone goes in and gets a negative result, that’s a chance for a conversation either in person or now through telehealth about whether PrEP might be an important option to stay HIV negative. We know that there are several important barriers to testing among young men who have sex with men or gay and bisexual men. One is that often, the risk perception is a little bit different than the risk reality, that men sort of feel like if they only have one partner that they’re not at high risk for HIV. And of course, if that one partner they have is also not living with HIV, that risk may be quite low. But because this piece of knowledge is awareness, if nearly half of young, gay and bisexual men who have HIV, don’t know that they’re living with HIV, they also can’t communicate that to their partner. So, risk perception may be low. Depending on how young men are, the options to be tested may be limited. I think they are concerned sometimes about asking to be HIV tested or by going to be HIV tested they might reveal information to family or to parents that they’re not ready to reveal yet. So, this issue about communication and how men decide to seek testing and where they decide to get testing and how that looks with respect to confidentiality and what they’re ready to disclose to parents can be an issue as well.
Professor Sullivan That is governed by state law, but everywhere in the United States, those 13 and older can seek testing for sexually transmitted infections, including HIV, without parental consent. I think part of that is that the knowledge of it may be imperfect among younger people and also just some other practical concerns. For example, if someone doesn’t have a driver’s license yet they may rely on parents for transportation or need to rely on public transportation. So, I think it is important to say that the accessibility of those tests without disclosing to parents certainly would be true across the United States, but also to think about ways to make it easier for men – for young men to seek the testing that they might need in ways that are confidential and that fits into the other parts of their lives, which at some point may include a school day schedule and normal times or coordinating this with other activities. So, I think most people would say that we have to be pursuing multiple ways in the fight against this virus and certainly vaccines are a critical part of a long-term picture. I think it’s important to remind people as you’re suggesting that there are weekly, monthly, every year, there are exciting discoveries that move along that knowledge but also that the immune system and the viral interaction with it are complex and that it’s not always possible to predict just from basic laboratory data which approaches may be successful. So I think we should really be thankful that there’s been a long term investment by both the U.S. government and by private funders in developing really an enterprise globally to be able to test these vaccines. But I think for the vaccine development, especially for a virus like HIV, we have to think of it as a marathon and we’re happy for the milestones. We’re happy about the new discoveries. But keep that as part of what’s going to be necessary to really eradicate this virus in the future. We’re on that journey towards vaccines. At the same time, we have to use the tools that we have and so, these two things interact. Even as we’re trying to increase the capacity and increase the coverage of PrEP in new ways. Data from other cities, data from London for example, suggests that with an adequate surge in PrEP coverage that alone really can result in important decreases in new HIV infections. Modeling work that we’ve done at Emory University and with colleagues around the world suggests that among gay men if you can get to 30 to 50 percent of gay men with an indication for PrEP, that can actually reduce the incidence of HIV in the neighborhood of 25 percent. So again, not all the way there. We want to get to 75 percent, but there is good evidence that getting the right levels of PrEP uptake in the men most at risk can really drive down incidence. So, I think we have to focus both on the long-term opportunity and then what we can do today. We still have a lot of room to improve PrEP programs to reach the people who are most in need of PrEP and to do that in a way that’s equitable. That means equitable uptake in women and young women, that means equitable uptake for black Americans and Latino/Latinx Americans. And, I think there are still challenges with making sure that as these PrEP programs roll out that they roll out in ways that are equitable and reach the people who are at most need. Then I’ll put in that third pillar, which is that the attention to people living with HIV, helping everyone living with HIV learn their diagnosis and make that transition into care that has all these great benefits, benefits for individual health, for people to live healthy, to live long productive lives and at the same time, to reduce that risk or to make it impossible for people to transmit the virus on to other people. So, we really have to be thinking about this in multiple strategies. The PrEP side, the diagnosis, and treatment side. Then in the long-term, things like vaccines that include microbicides of products that we probably still have a ways to wait for. But it’s worth that investment and keeping that forward motion.
Professor Sullivan Generally, in the United States, the number of new diagnoses has been coming down by just a bit—just a bit every year. I think the issue is that we’re not seeing the pace of reductions that we’d like to see to hit those targets that have been established for reducing diagnoses in the United States. And, as I mentioned, we know that currently, if you think about the whole universe of HIV infections that happen within a year, about 1 in 5 of those are going to be diagnoses among 13 to 24-year-olds. Among 13 to 24-year-olds, those new diagnoses also aren’t spread out evenly. So, for example among young men who are diagnosed with HIV about 55 percent of them are African American or black Americans, among young women ages 13 to 24, 62 percent of those are young black women. So, just keeping an eye on it as we try to think about what it looks like to reduce new diagnoses by 50 percent or by 75 percent. That we’re going to have to pay attention, especially to young people, to the sort of patterns of this slow decline that are going to get us there. There are particular groups that we need to make sure have good access to testing and other resources. Those are the groups where we know the new diagnoses are congregating. Eight out of ten new diagnoses in young people are among young men who have sex with men. And, among young men, more than half of those are black. So, those resources need to be and are freely available.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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Patrick S. Sullivan
Emory University
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