Insights for Ending the HIV Epidemic from CROI 2020
As a participant in the recent virtual 2020 Conference on Retroviruses and Opportunistic Infections (CROI), I found several studies to be particularly relevant to stakeholders across the country who are working to achieve the goals of the Ending the HIV Epidemic: A Plan for America (EHE).
Dr. Alex Coutinho, Executive Director for Partners in Health in Rwanda, emphasized a number of principles in his opening plenary presentation that are also foundational principles for EHE. He emphasized the need to:
- Translate science into population impact by scaling up evidence-based interventions;
- Address barriers to this scale up, including stigma, lack of investments and policies that stand in the way of services for key populations;
- Put people at the center of the HIV response; and
- Put services in places where people live and work.
View Dr. Coutinho’s presentation “Translating HIV Science into Population Impact: A Reality Check from the Frontline.”Exit Disclaimer
Below are highlights from just a few of the CROI presentations that offered insights specific to one or more of the EHE four pillars: Diagnose, Treat, Prevent, or Respond.
Universal test and treat interventions can reduce HIV incidence—Dr. Kevin De Cock from the CDC’s bureau in Nairobi, Kenya, discussed lessons from several Universal Test and Treat (UTT) trials conducted in eastern and southern Africa. The trials highlighted the association between the prevalence of unsuppressed HIV viremia in the community and incidence of HIV. Dr. De Cock noted that the former is driven by testing, treatment uptake, and medication adherence among people living with HIV to achieve viral suppression. The trials, he concluded, showed that while UTT contributes to HIV incidence reduction (in fact, 3 of the 4 studies achieved the UNAIDS 90-90-90 targets in high prevalence communities), it does not result in HIV elimination. To achieve control of HIV, particularly in generalized epidemics, Dr. De Cock’s recommendations included: expanding HIV testing to reach the populations that have high HIV incidence and prevalence; using data to better understand who is HIV positive, and where they and their social networks are located; and focusing interventions in those populations and locations.
Streamlined care improved engagement and viral suppression—Dr. Matthew Hickey from the University of California, San Francisco, shared findings about the effect of a streamlined model of HIV care on time in care and viral suppression from the SEARCH trial conducted in Kenya and Uganda. Streamlined care included rapid starts of ART; patient-centered, multi-disease care and case management; improved clinic access through flexible clinic hours; increased appointment spacing; a patient hotline; appointment reminders via mobile phone; and a structured format for discussion of detectable and undetectable viral load results. The streamlined care intervention resulted in better care engagement for all patients and increased viral suppression rates among patients who had been on antiretroviral therapy but with an unsuppressed viral load. He concluded that the improved viral suppression rates were likely mediated by a reduction in barriers to care and improved engagement care. These are the types of care innovations that we are seeking in EHE to achieve similar results.
Data-to-care intervention can improve re-engagement in care, retention in care and viral suppression among PLWH who are out of care—Dr. Kathleen Brady from the Philadelphia Department of Public Health presented the city’s results from the CDC-sponsored Cooperative Re-Engagement Controlled Trial (CoRECT), the first randomized controlled trial evaluating the Data to Care model. Data to Care is a public health strategy that uses HIV surveillance and other data sources to identify persons who are not in HIV care and link them to appropriate medical care and social services, with the aim of improving HIV health outcomes. The Philadelphia public health department partnered with eight medical care facilities to share data to identify PLWH who were not engaged in care and help bring them back into care through the efforts of Disease Intervention Specialists, or DIS. A total of 898 patients from Philadelphia were randomized equally to the intervention and standard of care arms. Dr. Brady and colleagues found that patients receiving the intervention were more likely than those receiving the standard of care to re-engage in care within 90 days, more likely to be engaged in care one year later, and more likely to be virally suppressed within one year.
High prevalence and incidence of and significant disparities in HIV in rural Southern U.S.—Dr. Leandro Mena from the University of Mississippi Medical Center (UMMC) discussed data on the high prevalence and incidence of HIV in rural Southern U.S., along with significant disparities. These disparities, he stated, are the result of geographical and historical social and political inequities that undermine access to HIV prevention and care services. To end the epidemic, Dr. Mena recommended we engage traumatized, marginalized people on their terms and in their communities, making care easy and convenient. An example he provided was the PATHways Program at Vanderbilt Comprehensive Care Clinic in Nashville, designed for individuals who have not previously been virally suppressed or those at risk of falling out of care. This Advanced Practice Nurse-led interdisciplinary and intensive outpatient care model utilizes a novel multi-dimensional instrument to assess patient strengths and concerns to develop an individualized care plan. Each plan is implemented and monitored by the interdisciplinary team and with the support of local AIDS Services Organizations. The viral suppression rate among patients enrolled in this program is >80%.
Pharmacist-led rapid PrEP program can increase uptake—Dr. Mena also discussed UMMC’s Rapid PrEP pilot which was designed to address the high rates of attrition at each step of the PrEP care continuum among young, Black gay and bisexual men in Jackson, Mississippi. In this pharmacist-led program, which is facilitated by a collaborative practice agreement, patients receive a prescription for PrEP from the pharmacist the same day they are referred by an STD clinic or DIS staff. The pharmacist also makes an appointment with a clinical provider for baseline labs, which are completed after PrEP initiation. Having a pharmacist function as a navigator is advantageous since pharmacists are expert in medications, insurance and health services navigation, and patient assistance programs. This approach has significantly improved the PrEP care continuum with 96% of participants receiving a PrEP prescription, 68% filling the prescription (compared to 15% historically), and 60% attending the clinical provider appointment for labs (compared to 9% historically).
Applying EHE pillars when responding to a West Virginia HIV outbreak—Dr. Paul McClung from the CDC discussed the response to a large HIV outbreak in Cabell County, WV. The outbreak resulted in 82 new cases among people who inject drugs (PWIDs) between January 2018 and October 2019, compared to a baseline new case rate in the county of two per year. Molecular cluster analysis determined a transmission rate of 72 infections per 100 person-years, 18 times the estimated national rate. Injection drug use, homelessness, exchange of sex for money or goods, and a history of incarceration were factors in transmissions. Proven effective interventions from each of the EHE Pillars were quickly and creatively implemented to better reach PWID. Innovative approaches were employed, such as a peer recruitment strategy to engage people in HIV testing, education, and enrollment in syringe services programs, and interdisciplinary care coordination that included Data to Care and linkage to medication assisted treatment for opioid use disorder. The response, a collaboration among state and county health departments and the CDC, enhanced the state’s and county’s HIV prevention and care and public health infrastructures, improving service delivery to vulnerable communities and capacity to respond to future outbreaks.
Each of these presentations, and many others, from CROI 2020 offered insights, strategies, and/or tools that can be useful as we all work together to pursue the EHE goals. They underscore that the latest scientific advances in HIV prevention, care, and treatment can be applied to put the EHE goals within reach.