Taking on HIV Local Epidemic with Local Epidemiology

World AIDS day is about one week away and I think it is important to thing about progress against this infectious disease. While HIV/AIDS does not grab headlines in the manner of Ebola, foodborne outbreaks, or AFM (acute flaccid myelitis) it is important to realize that it is still very impactful in the US and in the world.

In 2018, though there still remains no feasible cure or vaccine there are a few important tools that have reshaped the way it approached.

One such tool is antiretroviral therapy. Many people realize that effective treatment cocktails have transformed HIV from a death sentence to a manageable chronic illness, but they do more than that. When someone is on antiretroviral therapy and their viral load (the amount of virus detectable in their blood) is undetectable. They are no longer contagious. Undetectable = Untransmittable (U = U). This means that treatment is prevention as those on therapy are unable to infect others.

A second tool, is pre-exposure prophylaxis (PrEP). PrEP is a means of protecting oneself from contracting HIV by taking two antiretroviral medications on a regular basis so if one encounters the virus during an activity such as sex, the drugs prevent infection from taking hold. While not a panacea, it is an unequivocal advance in HIV prevention and its scale up could make a significant dent in new HIV infections.

When most people think of HIV, they think of it is as the global problem that it is. However, the global pandemic is really the aggregation of local cases and outbreaks. In the Pittsburgh area, where I live and practice, there are several groups working to curtail infections locally. One such group, that I am part of, is AIDS Free Pittsburgh. This organization’s aim is to decrease new HIV diagnoses in Allegheny County, in which Pittsburgh is located, by 75% from 2015 levels (142 cases) and eliminate AIDS in the county by 2020.

Recent data shows that their concentrated approach of working with strategic partners to increase testing, increase linkage to care, and enhance PrEP prescribing has been effective. In 2017, just 100 new diagnoses of HIV were made in the county — representing a 30% decrease since the formation of the organization — with 26 new AIDS diagnoses.

Looking at the data, however, there clearly are epidemiological opportunities to further decrease the force of infection in the county. For example, 80% of new infections were in males with 61% being in men who have sex with men — a prime target for PrEP. In fact, it seems the 75% goal could almost be met with prevention activity in this subgroup. Injection drug use accounted for 8% of new infections — another transmission category easily amenable to interdiction through needle exchange.

The point I am trying to make is that the HIV crisis can be addressed in a meaningful way just by looking at one’s local epidemiology and tailoring approaches to address the nuances of the area. Other communities, would do well to learn from the example of AIDS Free Pittsburgh.

How To Survive A Plague: Much More Than a How-To Guide

Even for someone in infectious disease it is very hard, in 2017, to appreciate the enormity of the emergence of HIV in the United States in the early 1980s. HIV, a prototypical emerging infectious disease, has been transformed from one for which no treatments were available pre-1987 to one in which medical students are overwhelmed with trying to learn the various drugs that can be used against it (in the developed world).  The diagnosis of HIV is no longer the equivalent of a uniform death sentence (although I just witnessed an HIV patient die from an overwhelming infection this past Saturday).

It is well recognized that this transformation occurred with a full-throttled research agenda that delivered new drugs, new diagnostics, and pathbreaking identifications in immunology and virology culminating in the awarding of a Noble Prize. What isn't well recognized is the intransigent efforts of HIV activists to not allow this disease to become victim to bureaucratic inertia (or worse). This story is masterfully told by David France in How to Survive a Plague: The Inside Story of How Citizens and Science Tamed AIDS, a comprehensive narrative based on France's award-winning documentary of the same name. 

The book is a personal tour of those plague years in which little to nothing was known about the virus when death and despair was the norm. In this dismal context, a group of citizen activists, many of whom were literally fighting for their lives flourished alongside a select cadre of scientists and physicians who attacked this problem with the full force of their intellects. France's book weaves all these tales together and shows how these tandem tracks converged and diverged while all involved were navigating in a largely inhospital political environment.

In its chronicling of the origins and rise of AmFAR, ACT UP, GMHC, TAG, and many other organizations that sprang into action to face the pandemic, the book illustrates just how impactful citizen activists were. Their success was not just in raising awareness but was instrumental in drug development and treatment guideline promulgation.

That these early People with AIDS fought so valiantly, many to death, for their lives through every avenue, whether open or closed is heroic and admirable. The innovative solutions such as "buyers' clubs" that made experimental therapies available are one example. The best representation of this heroism, to me, was their refusal to let bureaucratic regulations stand in way of their lives. Their actions, particularly with the FDA, fundamentally altered the way things had been usually done. Such lessons could directly impact on current fights against modern infectious disease threats such as antibiotic resistant bacteria and emerging infectious diseases.

The book is full of powerful anecdotes and poignant incidents that should never be forgotten and now won't be.

Taking HIV "Treatment is Prevention" to New Heights

Somewhat missing from the headlines in recent days is a landmark HIV study the solidifies the concept that treatment is prevention. The back story to that important catch phrase is that, in the recent past, there was a real policy debate over where emphasis should be placed: on treatment or on prevention. One's answer to that question would have multiple cascading effects on which anti-HIV strategies were planned, evaluated, and promoted. 

All that changed with the publication of HPTN 052 which demonstrated a 96% reduction in sexual transmission of HIV in mostly hetorosexual serodiscordant couples when the HIV-infected member was on HIV therapy. This trial was revolutionary in that it showed that the HIV treatment vs. prevention debate rested on a false dichotomy. Its results changed the way HIV prevention was viewed and provided yet another reason to initative therapy as soon as possible in the HIV infected. Caveats to the generalizability of this study existed however and included the high number of heterosexual couples and a high use of condoms (94%). Despite these caveats, HPTN 052 was pathbreaking.

Buttressing and expanding HPTN 025 is the PARTNER study, recently published in JAMA. This study's aim was to assess the ability of antiretroviral therapy on the transmission of HIV in serodiscordant couples who regularly engaged in condomless sex. The results, which solidify the treatment as prevention, paradigm are stunning.

The trial included about 2/3 heterosexual couples and 1/3 men-who-have-sex with men (MSM) couples. Condom-less sex occurred between couples a median of 37 times per year. Strikingly, just 11 transmission events occurred with nearly 60,000 condom-less sex acts. The thing about the 11 HIV infections was they were not genetically linked to the other study partner, meaning these infections derived from an additional partner not in the study--a great example of the exception proving the rule. 

This study shows just how potent antiretroviral therapy is. It is not only life-saving for those who take it but extremely effective at extinguishing contagiousness. As we wait for a vaccine, antiretroviral therapy (treatment as well as pre-exposure prophylaxis) is the cornerstone to keeping HIV contained.

The Political Virus-A Review of AIDS: Between Science and Politics by Peter Piot

Infectious disease is, for better or worse, intertwined with politics in a manner no other form of medicine is. While certain infectious disease require core governmental functions such as quarantine to be exercised and bioweapons involve multiple aspects of government role in promoting national security, it goes beyond that -- as a daily perusal of the headlines in our post-Ebola world reveals. Of the infectious diseases, HIV is in a realm all of its own really marking a new phase in how politics and infectious disease interact. While tuberculosis, plague, cholera, yellow fever, and malaria all had political importance, HIV is sui generis. 

I recently finished an excellent, up-to-date guide to the global politics of HIV/AIDS by a major force in the field: AIDS: Between Science and Politics by Dr. Peter Piot, the 1st director of UNAIDS, one of the discoverers of Ebola, and the director of the famed London School of Tropical Medicine and Hygiene. 

The book is based on a series of lecturers Dr. Piot delivered and covers the most pressing aspects of the global battle against HIV/AIDS which is now in its 4th decade. Throughout the book, Dr. Piot concretizes the nuances of the HIV pandemic with special attention to its heterogeneity ("know your epidemic") and the vicissitudes of infection rates, including the alarming increase in cases in American bisexual and homosexual men causing HIV rates in New York City and Washington DC to eclipse rates in some African countries. Dr. Piot also expertly emphasizes that the HIV pandemic is not explained by a simple linear model. For example industrialization can, depending on the context, foster or hinder the spread of HIV. 

Arguing for renewed efforts to harness all the scientific knowledge gleaned--which now includes pathbreaking concepts such as treatment-as-prevention, PrEP, needle exchange, decriminalization of sex work--Piot provides a path forward for controlling what has become the emblematic infectious disease emergency of our time, which killed 1.2 million people in 2014 and approximately 40 million since its jump into our species. 

Voices in the Band: Immersion in an American Epicenter of the HIV Pandemic

Because of my irregular schedule, I don't do outpatient infectious disease work anymore. There are times that I am thankful I made that decision, especially when a "chronic" Lyme patient happens to stumble upon my name online and wants to see me, and times I think about finding a way to do some outpatient work. Those positive thoughts are usually triggered by remembering my experiences treating HIV in an outpatient setting. It's not that I don't see HIV patients in the hospital and don't keep up with HIV anymore -- I am on Pittsburgh's HIV commission -- there's just something I miss about taking care of HIV patients in the outpatient setting. Outpatient care, I think, is much more personal allowing the physician to truly know a patient and the ups and downs of an illness over a longer period of time than during acute and brief episodes in the hospital. The satisfaction of seeing medications work or strategizing with a patient over the best long-term plan of care are all hallmarks of outpatient care that I sometimes miss.

It may seem odd that someone misses HIV clinic, but if you have ever practiced in one you would know exactly what I mean. I just finished Dr. Susan Ball's Voices in the Band: A Doctor, Her Patients, and How the Outlook on AIDS Care Changed from Doomed to Hopeful a memoir of her day-to-day work at the renowned HIV clinic at Cornell in New York City the Center for Special Studies, and all my own memories are becoming vivid again. 

Dr. Ball's tenure, which is ongoing, spans an important epoch in HIV history that saw HIV metamorphose, through the development of antiretroviral therapies, from a death sentence to a chronic illness and her narrative is therefore uniquely positioned to tell this important story.

Voices in the Band is a poignant, emotion-evoking story of one dedicated physician's experience of being literally immersed in a plague in which people died, orphans abounded, and myriad social calamities compounded the destruction wrought by a virus. As she puts it, "HIV existed as an addendum" in many patient's lives. Dr. Ball's vignettes of patients, their stories, and their coping mechanisms coupled with her own mind's analysis of how to provide the best care possible was, to me, the best feature of this book. Understanding her perspective and how she integrated each patient's individual context, some of which were endlessly complex, was, to me, the best aspect of this book. 

While the unique situations faced by an HIV physician in one of the epicenter's of the pandemic during its heyday may be appear, at first glance, to be very different to what a clinician treating HIV today may face, many of the same issues -- save the lack of effective therapies -- persist.

Dr. Ball's resilience and unequivocal commitment in being the best physician to her patients shines through the book and is exemplary. When she describes writes of her practice, "So much I’ve seen and so much more still to see" one is glimpsing the standing order of an active mind engaged passionately in a productive activity that it loves.

One of my favorite descriptions is her view of the role of an HIV (or infectious disease physician) as "trekking on another planet, exploring unknown territory where few wanted to go...where we shared a sense of being alive, of doing something brave and important."