The State of HIV Treatment and Prevention in the United States

The US Department of Health and Human Services (HHS)-led Ending the HIV Epidemic initiative aims to end the HIV epidemic in the United States by 2030. An analysis published in the US Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report suggests that substantial challenges lie ahead in the effort.

The authors of the report used National HIV Surveillance System data to estimate the annual number of new infections, estimate the percentage of infections which led to an HIV diagnosis, and evaluate the percentage of individuals with viral load suppression.

Pre-exposure prophylaxis (PrEP) coverage was estimated by analyzing national pharmacy data from the IQVIA Real World Data-Longitudinal Prescriptions database. The estimation was calculated as the number of persons who were prescribed PrEP divided by the estimated number of persons who had indications for PrEP.

The report highlighted a variety of barriers including the underutilization of pre-exposure prophylaxis (PrEP) and groups of Americans living with HIV who either don’t know it or aren’t accessing effective treatment.

Among the estimated 1.2 million people living with HIV in the United States in 2017, 14.2% had not received a laboratory-confirmed diagnosis. Of the 854,206 people with diagnosed infections, 62.7% had a suppressed viral load.

The lowest percentages of viral suppression were found among those aged 13-24 years, black individuals, and heterosexual males.

Report authors pointed to health care coverage, homelessness, and incarceration as potential drivers of lower medication adherence or viral suppression, particularly among at-risk black individuals.

“Since 2012, prompt treatment with antiretroviral therapy after diagnosis of HIV infection, regardless of stage of disease, has been recommended,” report authors wrote.

At the state level, low viral suppression rates within 6 months of HIV diagnosis (59%) were concentrated in the South, which authors noted is already disproportionately impacted by HIV.

Areas for improvement were also found in analysis of PrEP coverage.

Approximately 1.2 million people were estimated to have indications for PrEP in the United States. Of these individuals, 12.6% were prescribed PrEP in 2017 and 18.1% were prescribed PrEP in 2018.

PrEP coverage was 5.9% for blacks, 10.9% for Hispanics/Latinos, and 42.1% for whites. This indicates a racial disparity relative to coverage which is itself suboptimal among whites.

The United States is not alone in underutilization of PrEP. Europe’s PrEP gap of 500,000 MSM who need PrEP but can’t access it points to a global issue.

The report also discussed overall progress in terms of reducing HIV infections from the 2013 to 2018 period, noting that the number of annual infections has remained stable rather than decreased.

“Since 2013, progress in reducing the number of new HIV infections has stalled at approximately 38,000 new infections occurring each year,” authors of the report wrote.

“Accelerated efforts to diagnose, treat, and prevent HIV infection are urgently needed,” the authors concluded.