2012 overall world AIDS stats: Good news

As more of the 34 million with HIV gain access to antiviral therapy, fewer are dying of HIV infection. This is especially true in sub-Saharan Africa, according to a recent UN report. The decreases in deaths show that providing therapies to the developed world is working. Around 60 percent of the more than thirty million with HIV worldwide are on treatment. World health organizations such as UNAIDS have set a goal of significantly increasing that number by 2015. That requires $5 billion more in funding, however. Considering the world economic climate, that money may be hard to come by.

Triple Trifecta: Landmark HTPN 052 study keeps on giving

Several studies now show that providing anitivirals for those with HIV could significantly help end the HIV pandemic. That is because HIV infected people who take antiviral drugs are far less infectious. This treatment-as-prevention approach (also known as TasP) has been shown to reduce the HIV transmission by up to 96%. That is, at least among people who are more frequently exposed to HIV such as HIV negative spouses of those with the virus.

Of these studies, the ground-breaking treatment-as-prevention study, HPTN 052, is showing that those who start treatment earlier are less likely to develop HIV related infections than those starting later. Those who started treatment when their CD4 immune cell counts were higher suffered fewer HIV related infections than those who delayed treatment.

Another benefit to treatment-as-prevention is that it could save money as well as lives. Published studies already reveal that providing HIV treatment - - instead of allowing millions of people to get sick and die --- has positive effects on AIDS ravaged national economies. An important cost/benefit study presented at the International AIDS Conference (IAC 2012) showed that early implementation of treatment-as-prevention on a massive scale (in India and South Africa) would be more cost effective than delaying treatment access in those countries.

Study researcher Dr. Rochelle Walensky called TasP a triple trifecta: HIV-infected patients remain healthy longer, their partners are protected from the virus, and it is cost-effective. "Regardless of the country setting," she added, "over the long-term, treatment as prevention offers excellent return on its investment."

Romneycare and a Massachusetts miracle?

Last year, a study by the Africa Centre for Health and Population Studies revealed that treatment-as-prevention works on a community-wide scale. The study, done in the South African province of KwaZulu-Natal, found that transmission rates of the virus to others decreased as more HIV-infected community members got on treatment.

Something similar seems to be happening in Massachusetts and it may be due to the states mandatory health insurance program known as Romneycare. Since Massachusetts implemented the program in 2006 the rate of new HIV infections have been declining. That's probably because 98% of Bay State residents now have health insurance so residents with HIV have access to care and treatment. That means fewer infectious state residents to spread HIV.

Tragically, HIV infection rates are not going down in states where people can’t readily get health insurance. To make things worse, some states are fighting Medicaid expansion of Obamacare. That expansion would provide health care to millions of people including many with HIV.

Many of these states (in the south in particular) are also where the epidemic is exploding. Fewer people with insurance means fewer on HIV treatment. That also means more people will be likely to infect others and so fuel the spread of the virus.

In Massachusetts, however, universal health coverage is not only lowering HIV transmission rates, it's saving the state money — a lot of money in fact. Studies show that for every new Massachusetts infection that is prevented, the government saves about $500,000!

Save lives and money. Now that’s a great deal. So take heed America.

The Continuum of Care: Slipping through the cracks

The CDC estimates that 1.1 million people in the United States have HIV. However, about one in five are not aware of it, and they may be disproportionately responsible for the 50,000 new HIV infections that occur in the U.S. each year. Alarming data which the CDC recently updated at IAC 2012 showed that only a quarter of all Americans with HIV have their virus under control. So just in the U.S., there is a lot of work still to be done to stop the virus.

An infamous graph: Failure in the continuum of care

Earlier testing, wider screening

One increasingly important way of getting people into care is to regularly screen for HIV. The new OraQuick In-Home HIV Test should make that ever more possible. The in-home test provides results in around 30 minutes. As part of an aggressive public health testing campaign, HIV epicenters, like Washington D.C., are offering new quickie HIV tests in hair salons, barber shops, even the DMV as people wait to take their drivers test. In highly infected neighborhoods of Philadelphia, faith leaders are offering testing door to door. In L.A. the AIDS Healthcare Foundation, with celebrities in tow, has been hitting the clubs to offer a next-generation HIV test that provides results in minutes. These new and aggressive outreach screening efforts get people tested and if need be, into treatment.

And there is good reason for doing so. More and more studies show that HIV does considerable damage during the early, so-called, asymptomatic stage of infection. Earlier treatment can help prevent the damage related to HIV infection. These include:

•Chronic hyper-Inflammation of the immune system (inflammation that also has been tied to cancer and heart disease).
•Physical degradation of the lymph system and irreversible damage and reductions in vital immune cells (cd4, cd8, dendrites).
•Neurological damage, especially caused by certain strains of HIV.
•HIV seeding of reservoirs throughout body. Such seeding may diminish the likelihood of being cured of HIV one day.
•And, oh yes. Earlier treatment prolongs survival.

With early treatment making more sense, the U.S. Department of Health and Human Services and International AIDS Society-USA recently updated their HIV treatment guidelines. They now recommend that everyone with HIV, regardless of CD4 count, should be offered treatment. This reflects a worldwide shift toward earlier treatment intervention for everyone who has HIV. A big reason for this is the potential benefit that treatment-as-prevention could have in containing and possibly even ending the worldwide epidemic.

High Risk: The biology of MSM transmission

Thanks to treatments advances, HIV transmission rates and deaths are declining throughout the world. However, among men who have sex with men (MSM) the epidemic rages on. In the U.S., new infection rates among MSM have been increasing by around 8% per year since 2001. One reason, according to a study in The Lancet, is that the risk of HIV transmission through anal sex is 18-times greater than vaginal intercourse. The study adds that if casual MSM partners only had sex within long-term partnerships, HIV infections would decrease by 29-51%. The data also raises an important question. Will TasP, with its 96% level of protection, work as well for MSM as it did for heterosexual couples. Only 3% in the famed HTPN 052 study were MSM.

Another factor contributing to HIV transmission is acute infection. That period of just days or a little longer after someone is exposed to HIV. During acute infection HIV viral load levels explode. Sometimes flu-like symptoms also occur. During this period people can be highly infectious, yet most people don't realize they have contracted HIV and so they continue to take risks. So even if you have tested negative recently but are sexually active, don't let your guard down and assume you are not HIV infected. Always play like you (and your partner) have the virus.

Viral diversity and men at risk

Data presented by Dr. Damien Tully at the AIDS Vaccine Conference 2012 held in Boston showed that many MSM may be infected with widely diverse strains of HIV. The study, which is still ongoing, examined the virus of 22 MSM who had just become infected. About half of those in the study had several variations of the virus. This is a concern because viral diversity can speed HIV disease progression. The findings also mean that it could be more of a challenge to discover an effective vaccine that will work among MSM.

Dr. Tully's study also revealed another problem: sexual ecology, or the regular sexual partnering within a certain group. Doing so can increase the risk of contracting any illnesses or infections within that group. Many of the men in Dr. Tully's study, all whom are Boston based, were shown to be infected with the same, closely related strains of HIV. A study among African American MSM a few years back found the men believed they were less at risk of HIV exposure when partnering with other black MSM. This despite the fact that Black MSM have high rates of HIV. The takeaway? HIV can sometimes be "all in the family". So be wary of those you think you know. Don't let your guard down in the bedroom.

HIV and Black MSM

According to other Lancet data, black MSM around the world are much more likely to have HIV. The disparity is especially high in the USA and UK. Also according to the Lancet, black MSM in the U.S. now make up nearly one in six of all people with HIV. At IAC 2012, Dr. Karen Oster presented data on the black MSM "Brothers" study. It found that over just one year, new HIV infections among these men increased by 2.3%. Among those under the age of 30 the infection rate was an alarming 6%! The latter strongly suggests that if the trend continues, by the time they are in their 40’s, most urban black MSM will have HIV.

Dr. Greg Millett of the CDC told IAC 2012 attendees that the reason for high black MSM infections is not because these men are having more at risk sex than their white counterparts. He said studies show that generally these men are more sexually cautious and less likely to have substance abuse issues than white MSM. Recent CDC data also shows that risky behavior among all black teens has declined significantly. Instead, care access problems and sexual ecology are driving the black MSM epidemic, according to Dr. Millet. New infections are coming from repeated partnering within a highly infected community. Again, the takeaway is to be aware of the risk of exposure within these high prevalence "pools" and not just minimize risk during sex.