Why the U.S. Trails in Delivering HIV Treatment Goals

Trump Administration Inaction Erases Obama-Era Goals

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Of the eight European and high-income countries included in a review of national HIV strategies, the U.S. came next to last in ensuring many of the strategic goals of HIV testing, treatment, and management. As reported at the 2014 International Congress on Drug Therapy in HIV Infection in Glasgow, only Georgia—a small, unitary republic in Eastern Europe in which 34 percent of the population lives below the poverty line—fared worse.

According to the study, a mere 25 percent of Americans with HIV who are on antiretroviral therapy (ART) are able to achieve and maintain the goalpost standard of an undetectable viral load (defined as under 50 copies/mL). Moreover, of the 66 percent actively linked to care, only 33 percent are on ART despite national guidelines calling for treatment upon diagnosis.

The review of the national HIV treatment cascades assessed not only the percentage of people who were tested for HIV in each country but the percentage who were linked to care, are provided treatment and are able to achieve full and sustained viral suppression. The selection of the eight countries was based on the quality of available data from 2010 to 2012, extracted from a combination of national HIV reports, the UNAIDS database, peer-reviewed articles, and other sources.

HIV Treatment Cascades in Eight European and High-Income Countries

CountryPeople with HIV (est.)HIV Prevalence (%)Diagnosed with HIV (%)Linked to Care (%)On ART (%)Undetectable Viral Load (%)
Australia33,0000.275--3532
British Columbia11,700--71675135
Denmark6,5000.285816259
France149,9000.481>74>6052
Georgia4,9000.252442620
Netherlands25,0000.2--735953
United Kingdom98,4000.3--796758
United States1,148,2000.682663325

Key among the reasons for the U.S.'s poor showing was a high annual HIV incidence rate—in fact, the highest of all eight countries, with 15.3 persons infected per 100,000 (or approximately 50,000 new HIV diagnoses each year).  By comparison, the median incidence rate was less than half that number, or around 6.3 infections per 100,000.

Among the eight countries included in the review, most demonstrated an HIV diagnosis rate of between 71 percent and 85 percent (with the exception of Georgia, the only non-high-income country). While the percentage linked to care in high-income countries was relatively equal (with only the U.S. and British Columbia falling beneath the 70 percent threshold), greater disparities were seen once ART delivery was assessed, with the U.S. and Australia reporting that only 33 percent and 35 percent of their HIV-infected population, respectively, were on treatment.

(What the study does not show is that the U.S. also has the worst record for retaining patients in care, losing nearly half to follow up after their initial visits.)

Once on ART, the numbers only worsened for the U.S., with a mere one-in-four able to achieve complete viral suppression. In fact, as a whole, European countries demonstrated far higher undetectable HIV rates than that of North America and Australia (48 percent versus 27 percent, respectively).

Explaining the Disparities

While there is no one explanation for these figures, most agree that inequity in access to HIV care remains at the heart of the disparities.

In Georgia, for example—the worst performer on the list—an estimated 30 percent of the population avoid medical services as a result of high out-of-pocket expenses, particularly the cost of pharmaceutical drugs.

Meanwhile, legislation to enact social health insurance in the 1990s has largely been abandoned in favor of private health insurance, while 80 percent of the public hospitals have been sold to the private sector as part of the government's health and social reforms programs.

Similarly in the U.S., prior to the enactment of the Affordable Care Act (ACA) in 2014, access to care for Americans with HIV had been considered poor, with only 17 percent able to access to private health insurance versus 54 percent of the general population. And, until as late as 2013, the backlog for the government's AIDS Drug Assistance Program (ADAP) had been so long that some patients had to wait for as long as five years to access qualified drug payment subsidies.

Further impacting the U.S.'s standing was the lack of a clear domestic HIV strategy, with an earlier attempt by the Clinton administration failing to include either a timeline for meeting specific goals or details as to which federal offices were responsible for many of these goals.

The widespread geographic distribution of its HIV population—as well as the state-by-state variability of Medicaid eligibility—further compounded U.S. efforts, leaving many public health authorities without the central coordination that could have unified a national response.

Obama Era Aims Dimmed by Trump Administration

In an effort to reinvigorate the federal response to the epidemic, the Obama administration updated its National HIV/AIDS Strategy for the United States (NHAS). Under the NHAS, the federal government aims to achieve four key goals by 2020:

  • Increase the percentage of people living with HIV who know their serostatus to at least 90 percent.
  • Reduce the number of new diagnoses by at least 25 percent.
  • Reduce the percentage of young gay and bisexual men who have engaged in HIV-risk behaviors by at least 10 percent.
  • Increase the percentage of newly diagnosed persons linked to HIV-specific medical care within one month of their HIV diagnosis to at least 85 percent.
  • Increase the percentage of persons with diagnosed HIV infection who are retained in HIV-specific medical care to at least 90 percent.
  • Increase the percentage of persons with diagnosed HIV infection who are retained in HIV-specific medical care to at least 90 percent.

  • Increase the percentage of persons with diagnosed HIV infection who are virally suppressed to at least 80 percent.

While it is estimated that the cost of the NHAS would be in the range of $15 billion over the five-year period, some have suggested that the savings to the U.S. healthcare system—both in terms of averted infections and death—could be as high as $18 billion.

The likelihood of committing this level of investment under the Trump Administration appears slim given the GOP's aim of turning back many of the facets of the ACA and drastically retooling Medicaid programs meant to provide healthcare to poorer, vulnerable communities.

In October 2017, the President went one step further in undermining national HIV efforts by signing an executive order which allows employers to deny birth control as dictated by the ACA's Essential Benefit requirements. The order was based on the assertion that employers should be allowed to deny birth control based, not on economic reasons, but purely on religious or "moral" reasons.

It harkens to efforts by the Republican Party in the late 1990s to deny funding to African-based HIV charities who promoted any form of family planning, including birth control or abortion. It was (and remains) a cornerstone of an ill-founded yet oft-repeated abstinence-based GOP doctrine that invariably increases rates of HIV and other sexually transmitted infections.

The apparent disinterest of the Trump administration has been further evidenced by the fact that NHAS goals have been completely erased from the government's HIV.gov website.

It remains unclear what, if anything, the Trump administration will do to address or even acknowledge the current crisis in hard-hit African American and gay communities. In a review of the World Health Organization's HIV/AIDS database, the U.S. came in dead last with not only the highest HIV incidence of all high-income countries in North America and Europe but also the second highest HIV prevalence—surpassed only by Latvia at 0.7 percent.

Sources:

Centers for Disease Control and Prevention (CDC). "CDC Fact Sheet | HIV in the United States: The Stages of Care." Atlanta, Georgia; published July 2012.

Raymond, A.; Hill, A.; and Pozniak, A. "Large disparities in HIV treatment cascades between eight European and high-income countries – analysis of breakpoints." International Congress on Drug Therapy in HIV Infection; Glasgow, Scotland; November 2-6, 2014; abstract O237.

World Health Organization (WHO). “Prevalence of HIV among adult 15 to 49 – Data by country.” Geneva, Switzerland; updated November 6, 2014.

Yahia, B. and Frank, I. "Battling AIDS in America: An Evaluation of the National HIV/AIDS Strategy." American Journal of Public Health. September 2011; 101(9):e4-e8.

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