LLU researcher campaigns to significantly reduce spread of HIV/AIDS

Loma Linda Today
February 22, 2013

by James Ponder

A Loma Linda University HIV/AIDS researcher says he knows how to significantly reduce the number of new HIV cases in the United States.

Ron Hattis, MD, MPH, associate professor of preventive medicine, and president of Beyond AIDS, says that if American public health officials would fully embrace a finding he and a colleague discovered more than a decade-and-a-half ago, the rate of new HIV cases would fall dramatically in the United States.

The discovery—that treating new cases of HIV infection as soon as they are diagnosed rather than following the current policy of waiting several years—enjoys powerful support among the community of HIV/AIDS researchers and activists, who have given it the title “treatment as prevention.”

In 2011, Science magazine named HIV treatment as prevention its “Breakthrough of the Year” after clinical trials conducted by the HIV Prevention Trials Network (HPTN) found that early administration of antiretroviral drugs reduced the risk of heterosexual transmission of the disease by 96 percent, when compared with patients who were not yet being treated. Dr. Hattis notes that since HIV belongs to a group of viruses called retroviruses, drugs that treat HIV infection by attacking the virus are referred to as antiretroviral.

The concept of treatment as prevention is anything but new. In 1996, Dr. Hattis and former Loma Linda University public health resident Holly Jason-Kibble, MD, MPH, alerted the world to its enormous effectiveness through a literature survey they conducted and published that year.

“We went through the literature to find out why we couldn’t make people less infectious and stop the spread of the disease through merely treating them,” Dr. Hattis remembers. “For some reason, the government wasn’t promoting that for HIV.”

Despite the fact that it’s been more than 16 years since the pair released their findings, and nearly three years since the corroborating HPTN study, Dr. Hattis says government health agencies are still slow to develop and implement new policies and procedures that could potentially prevent tens of thousands of new HIV cases in the United States each year. Internationally, the impact would be even greater.

“The global potential could be the saving of millions of lives worldwide,” he points out.

However, he quickly notes that timing is of paramount importance in the battle against the epidemic.

“The use of treatment to suppress infectiousness is only effective when new infections are identified soon after they occur,” Dr. Hattis observes.

He explains that when treatment is started early and maintained, the reduction in new cases is phenomenal. Of course, he and Dr. Jason have been saying that for a long, long time. Ironically, their findings were released the same year the highly effective three-drug combination that currently forms the backbone of HIV treatment regimens was first approved.

“At that time, ‘hit early, hit hard’ was a popular idea for fighting the virus with drugs,” he recalls. “Regretfully, the idea soon lost support.”

Until last year, the government policy toward new HIV cases was to withhold treatment until the patient’s CD-4 count declined from 1,000, a normal level for an uninfected individual, to 500.

“CD-4 cells, or T-helper cells, are a type of white blood cell that fights infection,” he explains. “The CD-4 count indicates the stage of HIV or AIDS in a patient’s bloodstream.”

Earlier policies had mandated waiting until the score fell below 200, a process that can take between five and ten years. A CD-4 score of 1,000 is considered normal for an uninfected individual.

The problem with waiting several years to initiate treatment is that the disease remains infectious in the patient’s body, and any sharing of bodily fluids can lead to new infections. However, once treatment is initiated, the risk of passing the disease to others declines dramatically.

“Advisory panels finally changed their positions in 2012,” he adds. “That’s when they concurred that treatment with antiretroviral drugs should be offered without delay to every HIV patient.”

Several factors inf luenced the longoverdue change: new drugs are less toxic and easier to take; the theoretical problem of medication resistance turned out to be far less severe than originally feared; resistance is easily detectable by testing; and effective alternative medications are readily available.

But aside from the enormous benefit of preventing transmission of the virus to the partners of infected patients, policymakers were also significantly impressed by the fact that patients live longer and stay healthier when treatment is started early and maintained consistently.

“There are many benefits to the patient as well as to the public health,” Dr. Hattis contends.

He cites increased longevity and reduced chronic inflammation as reasons why patients who receive early and consistent treatment enjoy significant reductions in heart and kidney disease, diabetes, and tuberculosis versus patients who wait several years before starting medication.

“Many HIV patients also have hepatitis C,” he continues. “The reduced immunity that results from making them wait several years before the onset of treatment allows other chronic infections, such as hepatitis, to progress faster towards cirrhosis, liver cancer, or liver failure.”

Like many public health issues, the eradication of HIV/AIDS is highly politicized because of confidentiality concerns.

“Until a few years ago, HIV wasn’t even reportable to public health agencies,” he says. “AIDS was, but HIV wasn’t. When it was understood that HIV is caused by a virus, the HIV community said, ‘There’s a lot of stigma here. Let patients have their privacy until the disease progresses to AIDS.’

“It took us 10 years to get the reporting requirement extended to HIV,” he confides. “Without finding infected people and getting them treated, the impact of treatment on prevention—and on the number of newcases—wasn’t outstandingly effective.”

Because newly identified HIV infections did not become reportable to public health officials until 2006 in California, it was difficult to ensure that patients were being referred for medical treatment. It was also hard to make sure that adequate testing was taking place among population groups with the highest number of new infections. These two factors served as barriers to treatment and exposed recently infected individuals to the negative health outcomes of delayed treatment.

In his role as president of Beyond AIDS, a non-profit organization dedicated to reversing the course of the HIV/AIDS epidemic through sound public policy, Dr. Hattis urges lawmakers, public health officials, and members of the HIV/AIDS community to implement treatment as prevention as the most promising control strategy on the horizon.

“One of the main recommendations is that we have to put more emphasis on controlling the disease at the source,” he says. “Now that HIV is reportable, doctors need to gather information on other people who may have been infected and may not know it.”

When a physician identifies someone newly tested as HIV-positive, the infected person often doesn’t realize he or she was exposed.

The process of interviewing a patient to determine others who may have been exposed, and subsequently inviting them in for testing and counseling, is called “partner services.” The law stipulates that only physicians or public health officials are allowed to perform partner services.

But thanks to the 2012 passage of a law sponsored by Beyond AIDS, California physicians without the time or expertise to perform a partner services evaluation may refer the infected patient to the public health department if the patient consents. Either way, the law mandates that the identity of the source patient cannot be revealed.

“Partners of an HIV patient may not yet be infected and could be protected,” he warns. “In fact, the new patient may be among the most recently infected persons in the country.”

Dr. Hattis contends doctors could prevent many future infections by following three simple steps: first, reporting new cases to public health agencies at the time of diagnosis; second, performing or referring new patients for the partner services evaluation; and third, either initiating treatment or referring patients to a specialist for treatment as soon as possible after the diagnosis has been made.

“What it will take to stop the spread of HIV is a partnership between private medical providers and public health officials,” he declares. “Not enough has been done to get the word out to either health care providers or patients. Now that the benefits of early treatment have been recognized, Beyond AIDS believes that all the pieces are available to form a comprehensive strategy to steadily reduce the rate of new infections.”

The City of New York is already using such a strategy. Dr. Hattis proposes it be adapted as a template for an effective national policy. Cornerstones of the New York regimen, which is directed by an officer of Beyond AIDS, include:

Despite these advances, Dr. Hattis says statistics issued by the Centers for Disease Control and Prevention portray a depressing reality.

“Only 82 percent of infected persons have been tested,” he maintains. “Of those who have, one-third never made it to a doctor, perhaps because they were told they didn’t need to do anything yet.

“Of the two-thirds who have been linked to medical care,” he continues, “only about half have started on antiretroviral drugs. Altogether, only 25 percent of HIV-infected persons actually have the virus fully suppressed in their blood. ”

He points out that the 96 percent reduction in new infections that was reported in the HPTN study and published in Science represents patients from that latter group—the 25 percent whose virus is fully suppressed.

The fact that lawmakers and government health officials have been so slow to turn treatment as prevention into national law prompts a strong response.

“We can and must do much better than this,” he declares.

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