National HIV Prevention Conference 2015, Part 1: Incredible Successes, Intransigent Disparities

Four years ago, the last time the U.S. Centers for Disease Control and Prevention convened its National HIV Prevention Conference (NHPC), there was a lot of discussion about the potential for HIV antiviral treatment to foil HIV transmission. At the December 2015 NHPC, Anthony Fauci, the Director of the National Institute of Allergy and Infectious Disease, took the “potential” out of that assessment: “The message is that we can end the epidemic by following the science. The science has spoken—there can now be no excuse for inaction.”

Fauci was referring to treatment as prevention (TASP) and pre-exposure prophylaxis (PrEP). TASP is the use of HIV antiviral treatment to not only improve the health of people with HIV but also dramatically reduce the likelihood that they might transmit HIV to their HIV-negative partners. PrEP is the use of HIV antivirals by HIV-negative folks to protect them against the virus. And over the past four years, it has become abundantly clear that taken regularly as prescribed, each of these treatment regimens works.

The conference, according to staff from AHP’s Provider Training and Education Unit who attended it, focused on the challenges to implementing this vision: helping people “link to care,” assess whether these approaches are right for them, and, if so, sustain adherence to their medication so that it is effective. And, so it was no surprise that the conference also focused on many of the same issues that have always burdened HIV prevention efforts, in particular access to care, health disparities and stigma, such as homophobia and racism, but also psychiatric conditions and substance use.

One risk is that the move toward biomedical interventions will shortchange some of the more traditional interpersonal and psychosocial approaches and skills necessary to provide client-centered, culturally appropriate, and effective care. And, according to Provider Training and Education Unit Manager, Rob Marks, there was very little discussion of counseling at the sessions he attended. On the other hand, there was a great deal of discussion about how to define and respond to the social determinants of health and how to address health disparities.

Disparities were stark, particularly in light of so much success, and the success of the San Francisco model was a standout, in particular, identifying people with HIV and quickly ushering them into treatment. In the midst of good news about the percentage of HIV-positive people who know they are HIV-positive (87 percent! a big increase over the past 10 years), there was also the startling news that more than 60 percent of people with HIV are not in treatment and of those who are, many fall out of care, a crucial barrier to treatment as prevention. Further, although there has been a heartening reduction in the annual rate of new infections in some groups—most notably African American gay and bisexual men—there has not been a reduction in the rates in Latino gay and bisexual men. Perhaps the most startling disparity was regional: the southern United States is disproportionately affected, with lower percentages of HIV-positive people who know their status and significantly higher rates of death among people with HIV than other regions of the country. Stay tuned for part two of this report back which looks both at one of the key challenges to prevention—stigma—and one of the central issues facing community-based organizations in the age of the Affordable Care Act: funding.