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

Can the President's National HIV/AIDS Strategy Reverse the Tide?

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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% of the population lives below the poverty line—fared worse.

According to the study, a mere 25% 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% actively linked to care, only 33% are on ART despite national guidelines calling for treatment upon diagnosis.

The review of the national HIV treatment cascades (also known as the HIV care continuum) assessed not only the percentage of people tested for HIV in each country, but the percentage that 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 (%)
British Columbia11,700--71675135
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% and 85% (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% threshold), greater disparities were seen once ART delivery was assessed, with the U.S. and Australia reporting that only 33% and 35% 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, loosing 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% versus 27%, 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% 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% 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% able to access to private health insurance versus 54% 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.

Reversing the Cascade Tide?

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

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

While it is estimated that the cost of the NHAS will be in 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.

That's not to say that the goals will be easy to achieve or that the U.S. doesn't have a lot of ground to make up in order to come into line with other high-income countries. 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%.


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