Early HIV Treatment Is Essential, But So Is Testing And Linkage To Care

Health Affairs Blog

03/06/2015

Preeti N. Malani, MD, MSJ is a Professor of Medicine in the Division of Infectious Diseases at the University of Michigan and an Associate Editor of the Journal of the American Medical Association (JAMA).

Last week’s announcement of the Strategic Timing of AntiRetroviral Treatment (START) trial results confirms what many experts have long believed — early treatment for HIV reduces illness and death. While START further establishes the vital role of early antiretroviral therapy (ART), many questions remain on how to actually bring the life-saving benefits of treatment to individual patients.

In many regards, the very question over when to start treatment is unusual in the field of infectious disease. “No one says we shouldn’t treat TB [tuberculosis] until the size of your cavity is 5 centimeters or your sputum has four-plus AFB [acid fast bacilli],” explains Carlos del Rio, professor of medicine at Emory University and chair elect of the HIV Medical Association. “From a pathogen standpoint, treatment should begin right at the time of diagnosis,” del Rio says. “We need to move beyond the Byzantine discussion about when to start therapy.” In fact, U.S Guidelines have recommended ART for all HIV-infected individuals since 2012. However, several barriers remain to full implementation, beginning with testing and access to care.

HIV Testing

Before treatment can be offered, individuals who are HIV positive must first be identified. Yet, of the estimated 1.2 million Americans living with HIV infection, about 168,300 (14 percent) are unaware of their diagnosis. This is due in part to a number of road blocks that continue to make it difficult for people to get tested. Early in the AIDS epidemic, HIV testing sites were deliberately removed from routine care.

“History is destiny,” del Rio reflects. “In order to decrease stigma, we practiced AIDS exceptionalism. You would go across the street to get your HIV test.” Although this approach may have helped protect confidentiality during an earlier era, today it creates significant hurdles that prevent some people from learning their status. Besides physical barriers, many U.S. states still have requirements for formal pre-test and post-test counseling that add to the logistical burdens surrounding HIV testing—for both providers and patients.

It is time to rethink how, where, and when we test. By better integrating HIV testing into routine care, we can allow patients to be tested at the same place they go for a check-up or to have other chronic conditions managed and treated. Meanwhile we also need to make self-testing easier and more affordable. For many other conditions, from pregnancy to diabetes, self-testing is routine. Yet home testing for HIV remains limited in the U.S. Among the obstacles is cost; the $40-$50 price tag for a home-based test is often out of reach for at-risk populations who might benefit.

Access To Specialty Care

Once HIV infected individuals are identified, they deserve systems that are better equipped to seamlessly link them to specialized care. “We need to get people to care and make [the transition] smooth,” explains del Rio. A number of evidence-based approaches use intensive case management to ensure patients do not fall through the cracks after testing positive. These approaches have been associated with higher rates of linkage to HIV care, particularly for traditionally vulnerable populations. Still, linkage is not the only challenge — retention in care is an even bigger issue.

“We bring them in and lose them,” del Rio laments. He adds that we must bring resources to where the needs are, including areas that lack trained providers. Access to specialty care is particularly limited in rural areas. Successful models of care include enhanced telemedicine approaches that allow one or two HIV providers to cover a large geographic region. In addition to HIV expertise, adequate mental health and addiction treatment resources are desperately needed, and indispensable for boosting retention.

Accepting Imperfection

Current ART regimens are less complex, better tolerated, and more effective in terms of achieving viral suppression. Still, as with many chronic conditions, adherence to medications remains imperfect for many. Years ago, when pill burdens were high and the adverse effects severe, clinicians would generally hold off initiating ART until a patient could demonstrate the ability to consistently come to clinic. We required patients to jump through lots of hoops to begin therapy. In contrast, it’s hard to imagine a provider withholding diabetes treatment from patients who had failed to keep an appointment. We continue to treat diabetes despite imperfect adherence.

Given the strength of evidence that early treatment not only prevents HIV related complications but also prevents new infections by decreasing the risk of transmission, it behooves us to provide the necessary support—including formal adherence counseling—to make effective treatment a reality for everyone. Adherence is especially critical when treating HIV, so that resistance does not emerge. “We need to diagnose people, link them to care, retain them in care, and keep them on [HIV] drugs,” del Rio summarizes. “Everything else is icing.”

As HIV becomes more and more like any other chronic disease, primary care providers must become comfortable with the basics of HIV management. That includes approaching the disease as just one factor interwoven with myriad others to be considered when evaluating a patient’s overall health and well-being. Indeed, for a large portion of HIV infected patients in the US, their major medical care needs center, not on HIV itself, but rather on other chronic diseases, such as cardiovascular disease, diabetes, or hyperlipidemia.

Now in the fourth decade of our work to understand and treat HIV, we’ve learned that there are no silver bullets to eliminate this disease. Instead, every new discovery and revelation, as hopeful and encouraging as it is, also brings with it a reminder that there is more work to be done. The latest results and recommendations coming out of START are just that — not the finish line, but rather an important place to begin.