June 27 is National HIV Testing Day, and it comes amid a sweeping federal campaign to reduce new HIV infections in the United States by 90 percent over the next decade. The Trump administration wants to target “hotspots” where more than half of new HIV infections occur.
I practice in one of those hotspots — Franklin County, Ohio — where the annual incidence of HIV has not changed significantly for the past five years. When I look through records of my newly diagnosed patients, I often see they’ve had contact with the medical system in the past, but they were never offered an HIV test. For those who tested negative, opportunities to discuss HIV risk and to prescribe pre-exposure prophylaxis (PrEP), a daily medication that reduces the risk of getting HIV from sex, are often squandered. We’re missing multiple opportunities to diagnose patients early and get them started on antiretroviral treatment to prevent new infections.
In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) announced the “90-90-90” Fast-Track initiative to end the global HIV/AIDS epidemic by 2030. The UNAIDS goal is to have 90 percent of HIV-positive people know their status, link 90 percent of them to treatment and have suppression of the virus in at least 90 percent of that group. This would virtually eliminate the HIV epidemic. Several high- and low-income countries have already achieved these targets, but the U.S. lags behind.
About 38,000 American are diagnosed with HIV every year, a number that has remained stagnant since 2012. More than 1.1 million Americans are living with HIV, but 14 percent are unaware of their HIV status. Among young people living with HIV ages 13-24, this number is more than 50 percent.
We already have the tools to achieve the 90-90-90 targets — we just need to effectively use them. Those tools include promoting HIV screening, facilitating linkage to care (including through telemedicine) and using all resources available to ensure rapid treatment initiation, retention in care and maintaining viral suppression. Studies show the risk of sexual transmission of HIV is effectively zero when patients taking antiretroviral medication maintain viral suppression. This supports the message of the U=U (undetectable equals un-transmittable) campaign, which has been endorsed by the Centers for Disease Control and the National Institutes of Health.
At The Ohio State University Wexner Medical Center, we have developed a joint project between the Emergency Department and the Division of Infection Diseases to do HIV screening in the ER, which is sometimes the only point of access to health care for patients. Our team receives daily reports of all HIV and syphilis tests conducted in the ER, notifies patients of their results and rapidly links them to treatment or PrEP services if necessary. By streamlining our electronic medical records ordering and referrals and providing direct specialist support 24 hours a day, we have increased HIV testing from fewer than 100 HIV tests per year between 2012 and 2017 to more than 100 tests per month in just the first six months of the pilot project.
I’m calling on my colleagues to offer HIV tests on a routine basis and make HIV risk and sexual history a normal part of the conversation with patients of all ages. HIV testing should be offered not just in the usual health care settings, but where people gather regularly including bars, clubs, concert venues, community centers, high schools and churches.
Cities like San Francisco, New York and Washington, D.C., have dramatically reduced HIV incidence through programs that promote HIV testing, facilitate access to PrEP and rapidly initiate antiretroviral treatment. Other cities and communities can achieve similar results but must eliminate outdated policies that criminalize HIV and further stigmatize people. More than 30 states have prosecuted HIV-positive people for not disclosing their HIV status to sexual partners. These laws make people afraid to get an HIV test or disclose their status, rendering them effectively “invisible."
We have made great progress in the diagnosis, treatment and prevention of HIV. It’s now time to work together to reach that final goal elimination of HIV. We can start by making HIV testing a routine screening easily available to all Americans. If we also expand access to PrEP for people at risk of HIV and guarantee the availability of antiretroviral treatment for those living with HIV regardless of sex, age, race, ethnicity, geographic location, sexual orientation or gender identity, we will be able to eliminate HIV, not just in selected cities, but in all communities.
Carlos Malvestutto, MD, MPH, is board certified in internal medicine and infectious disease for The Ohio State University Wexner Medical Center. Dr. Malvestutto previously served as medical director of the Family AIDS Clinic and Education Services program at Nationwide Children’s Hospital.