Abstract
Thirty-five years since the first diagnoses of HIV infection in New York City, Los Angeles, and San Francisco, HIV remains a significant public health problem in affluent and resource-constrained countries alike. More than 35 million people have died of AIDS-related illnesses since the start of the HIV epidemic, and there are an estimated 37 million people living with HIV (PLHIV) globally. 1 In 2015, there were 2.1 million new HIV infections and 1.1 million AIDS-related deaths. 1 While the situation in the United States is far less dire and is improving due to recent efforts to optimize HIV care and prevention continua, the latest US Centers for Disease Control and Prevention (CDC) data indicate that 1.2 million people were estimated to be living with HIV in 2012, 13% of whom had not been diagnosed. 2 The CDC also estimated that 39 513 people were diagnosed with HIV infection in the United States in 2015. 2 Moreover, in 2015, 18,303 people were diagnosed with AIDS. Since the epidemic began in the early 1980s, 1,216,917 people have been diagnosed with AIDS. In 2014, there were 12,333 deaths (due to any cause) of people with diagnosed HIV infection ever classified as AIDS, and 6,721 deaths were attributed directly to HIV, 3 reflecting the outcome of late diagnosis and presentation for HIV treatment.
Scientific advances have yielded HIV treatment and other prevention interventions that can help achieve the goals of keeping PLHIV alive and healthy, preventing HIV transmission, and, ultimately, controlling the global HIV pandemic. Multiple observational and randomized clinical control studies demonstrate unequivocally that antiretroviral therapy (ART) prevents AIDS-related morbidity and mortality. 4,5 As an additional critical benefit it also prevents HIV transmission and, when delivered within an optimized HIV care environment, has the promise to control HIV. 6 The science also supports that ART should be started as soon as possible, irrespective of CD4 count, 7,8 and mathematical models indicate that expanded access to treatment could lead to HIV control and the eventual elimination of HIV. 9 –13 In addition to preventing illness, death, and transmission, earlier access to ART to prevent HIV transmission can reduce costs to the health sector, society, individual patients, and the community. 14,15 However, according to the latest CDC national HIV care continuum data, an estimated 14% of PLHIV in the United States in 2011 were undiagnosed, 60% were not engaged in HIV care, 63% were still not on ART and, of those who are on ART, only 30% achieved viral suppression, 16 without which the therapeutic and preventative benefits of ART are unrealized.
del Rio et al’s article in this issue of the
In their elegant study, the authors looked at hospital admissions for people newly diagnosed with HIV and AIDS at Grady Memorial Hospital in Atlanta for a 2-year period from 2011 to 2012. They found 92 people with a CD4 count <200 cells/mm3 who were diagnosed with an AIDS-defining illness on admission. Delayed HIV diagnosis is a significant individual and public problem. The authors state that around 20% to 50% of PLHIV in Atlanta are first diagnosed late with AIDS and this is reflected in their findings of the 179 hospital admissions with new HIV diagnoses, 92 of whom met the criteria for AIDS. Even more sobering is the fact that only 12% of the individuals newly diagnosed with AIDS were started on ART. Linkage to care is a critical aspect of the HIV care continuum and here del Rio et al found that only 44 (54%) of those discharged from the hospital were linked to HIV care within 3 months, and only 48 (59%) achieved viral suppression within one year.
Although the HIV care continua for Atlanta and other major cities in the United States have undoubtedly improved since the study period, the findings reported by del Rio et al are alarming and raise some serious issues. Most PLHIV in the United States know their serostatus, however, this study suggests that many vulnerable people are unaware in Atlanta and other urban settings. The current standard of HIV care and the NHAS targets suggests that admission without an HIV diagnosis and ART is both a clinical and public health failure, or a missed public health opportunity to prevent illness, death, and transmission. In an advanced industrialized society and one affluent enough to sustain the global AIDS response through bilateral and multilateral efforts, admission diagnoses with HIV and AIDS just should be exceedingly rare and can be compared to a hospital diabetes diagnoses only when someone is admitted with diabetic foot ulcers, renal failure, or loss of vision.
Improving access to HIV care and treatment remains a significant challenge in many urban settings. People who are vulnerable to HIV in our society face many other issues that often directly and indirectly affect their health. The cohort of patients in the del Rio et al study was mostly African American (80%), men and uninsured (75%), and around a third of those diagnosed with AIDS were substance users or men who have sex with men-the most vulnerable among us. HIV is a 100% fatal infectious disease with serious personal and public health importance. An HIV diagnosis should be treated as a clinical and public health emergency—relying on the chance and hope that someone newly diagnosed with HIV will find her/his way into care and onto ART are no longer acceptable. The individual and societal costs of our fragmented approach to HIV diagnosis, care and treatment, and epidemic control are just too high.
San Francisco and other cities have moved to a social support approach that includes same-day ART initiation and immediate engagement with social services upon HIV diagnosis, usually well before an AIDS diagnosis. As part of the Fast-Track Cities initiative, the International Association of Providers of AIDS Care (IAPAC) is working with high HIV burden cities in the United States and around the world to consider ways to implement same-day ART initiation upon diagnosis as well as immediate engagement with available social services. 19 Moving from “test and wait” to “test and treat” was the right move for the US Department Health Human Services (2012), IAPAC (2015), and World Health Organization (2015), 20 –22 but if we are serious about controlling the HIV epidemic, we must implement a higher standard of HIV care which is to “test, initiate same-day ART, and offer immediate social support.”
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.