HIV and ID Observations

With apologies to a 1960s band with a flair for complex harmonies and evoking warm ocean breezes (as the first winter storm barrels in), here’s a miscellaneous list of wishes for World AIDS Day.

Wouldn’t It Be Nice …

• If everyone with HIV could be on suppressive antiretroviral therapy? Here are the latest estimates, showing we’re only a bit more than halfway there:

It's #WorldAIDSDay.
There were approximately 37.9 million people living with #HIV at the end of 2018.
🔹79% had been diagnosed
🔹62% were receiving treatment
🔹53% had achieved suppression of the HIV virus to the point at which they were at low risk of infecting others. pic.twitter.com/L6Zlv31Gnk

— World Health Organization (WHO) (@WHO) November 30, 2019

• If antiretroviral therapy had no side effects? Our treatments are so much safer and better tolerated than they were — hooray! — but they’re not perfect. Weight gain is the latest adverse effect of greatest concern; Dr. Andrew Hill presented a superb summary on the topic at the recent European AIDS Clinical Society (EACS) meeting.
• If all those at high risk for acquiring HIV could receive PrEP? Here in the United States, the high price of PrEP draws the most attention as a barrier. However, the issue is far more complicated than just price (though that doesn’t help) — it starts with the fact that those at greatest risk of acquiring HIV here (young MSM of color, especially in the Southeast) are the least likely to be engaged in any longitudinal healthcare. And many countries don’t cover PrEP at all.
• If HIV stigma disappeared? All of us follow patients who have so internalized the societal stigma of having HIV that they can’t bear to tell anyone about their diagnosis — not even close family members or friends. Some have lived with this pain for decades. Boy, HIV really needs a stigma-ectomy.
• If the pricing of HIV medications in this country actually made sense? Imagine a world where setting the price of HIV drugs were a transparent process based on actual value, and didn’t involve convoluted, secret negotiations between payers, manufacturers, and pharmacy benefit managers? What a wonderful world that would be! (That’s a different song.)
• If the confirmatory test after a reactive HIV screen were an HIV RNA (viral load) rather than a HIV-1/2 antibody differentiation assay? As I’ve written before, this would greatly speed getting people an accurate diagnosis, and furthermore dramatically reduce the “worry days” with a false-positive screen.
• If every HIV resistance test a patient ever had were kept on a secure but easy-to-navigate site? HIV resistance testing entered clinical care in the late 1990s. It has been provided through multiple different labs with a dizzying array of reporting formats and interpretations. Poorly suited to display on electronic medical records, these reports are best seen in their original format. Perhaps a Dropbox-like repository, with a folder for each patient containing the reports? You’re welcome.
• If there were an effective HIV vaccine? As two major clinical trials proceed — HVTN 702 and 706 — we eagerly await results!
• If HIV could be cured? Last, but not least. We learned of our second case of likely HIV cure early this year at CROI, and a third is out there too. All three, however, required a stem cell transplant. While hardly a scalable approach, these cases prove that prolonged, drug-free remissions are achievable.

Surf’s up!