90 is the number… to end HIV
90–90–90 is an ambitious treatment target embraced by international agencies like UNAIDS to end the AIDS epidemic. Epidemiologists agree that meeting these numbers will lead to the effective end of HIV as a public health crisis. The goals break down like this:
- By 2020, 90% of all people living with HIV will know their HIV status.
- By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
- By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.
New York City has pioneered success
Once an epicenter of the American AIDS crisis, New York has taken the lead in the battle to defeat HIV. In a recent press release, the New York City Health Department announced that the City exceeded the 90–90–90 goal two years early. The number of new infections has dipped below 2,000 annually and is continuing to fall rapidly.
“New York City is charting a path to zero new diagnoses,” according to Health Commissioner Dr. Oxiris Barbot. “The roadmap to ending the epidemic includes celebrating healthy sexuality, making PrEP available for those who want it and fighting against the racism, sexism, homophobia and transphobia that drive transmission.”
Much of the credit for NYC’s success (and even much of the credit for new global plans to end HIV) belongs to Demetre Daskalakisa, a “radical gay doctor” who joined the NYC Health Department in 2013. He conceptualized and implemented strategies that focus on access to treatment both before and after at-risk patients test positive for HIV.
Status neutral care
Dr. Daskalakis promotes “status-neutral care,” which takes the same approach to initial patient care regardless of HIV status. His framework reduces HIV stigma and encourage frank discussions about sexual health, risk and prevention. He first proposed the details in an article in the medical journal Open Forum Infectious Diseases.
Then he got to work. He renovated and destigmatized STD clinics, rebranding them as sexual health clinics. He explains it this way:
All the services had to look alike, whether you’re HIV-positive or negative, and the idea was that if you come in and you are newly diagnosed with HIV you get started on meds on the same day of your diagnosis. If you are at risk for HIV, and you test HIV-negative, we don’t dilly dally and wait. We start you on PrEP that same day.
He replaced ad campaigns designed to shame people out of contracting HIV with a positive, empowering message about prevention:
“New boo? Get tested!”
In the status-neutral-care framework, testing is the first step to getting a patient started on either PrEP to prevent infection, or TasP to suppress HIV in patients so that they don’t become ill and can’t infect others.
Today, New York City has lower rates of new HIV infections than any other city in the US, with those rates projected to trend toward zero by 2022. The NYC Health Department has demonstrated that a combination of political will and cold cash can end the epidemic.
The 90–90–90 UNAID goals aren’t the only strategy for fighting HIV. Earlier this year, the Trump administration launched an initiative called “Ending the HIV Epidemic: A Plan for America.” The federal plan focuses on four key pillars — diagnose, treat, prevent and respond — using county-level HIV data to quickly identify where the virus is spreading.
While the plan is roughly similar to NYC’s successful campaign, activists have been skeptical about its chances for success, suspecting that a lack of political will and funding might get in the way of getting treatment to everyone who needs it.
Access to treatment is a problem for the federal plan
The federal Ryan White HIV/AIDS Program already acts as a “payer of last resort” for people living with HIV who can’t afford treatment, but that’s only half of the treatment pie. And access to even that program is beset with challenges. More on that later.
The piece of the federal pie that’s been missing up until now is PrEP. Ending HIV means treating people who test positive, but it also demands treating at-risk people who test negative. A status-neutral-care framework requires prevention on both sides of the testing coin.
Ready, Set, PrEP!
Health Secretary Alex Azar just announced the “Ready, Set, PrEP” program, calling it a “historic expansion of access to HIV prevention medication” and a “major step forward” in the Ending the HIV Epidemic plan.
The new program will distribute Truvada, the brand name of one of two Gilead Science PrEP formulations, to at-risk people who don’t have health insurance.
The program will follow a CDC risk index to determine eligibility. Men and transgender women who have sex with men would qualify for free PrEP if they have certain combinations of risk factors. One factor — having condomless receptive sex once in the past six months — would mean automatic free PrEP eligibility.
Steep barriers to access remain
The program suffers from a glaring deficiency: Ready, Set, PrEP does not cover the initial blood work fees needed to start treatment or the follow-up doctor’s visits and blood tests needed to stay on the drug.
The CDC’s 2017 PrEP provider guidelines require PrEP users to receive multiple blood tests annually in order to start PrEP and continue taking it. Tests cost hundreds of dollars per visit, not including physician fees, a steep barrier to access for people without health insurance.
Activists know that HIV is spreading most rapidly in communities where access to health care is a problem. People of color are most at risk, as well as people living in the American South, particularly the rural South. We won’t end HIV unless we can remove barriers to treatment for all.
Money is the issue
Access to testing and treatment is largely a function of state, county, and municipal budgeting. Even people living with HIV who qualify for the Ryan White Fund often go untreated because they don’t know how or can’t access testing and treatment at the local level.
The people who need free PrEP the most won’t be able to afford the gate-keeping fees to get them inside the system. HIV will continue to spread unless we can come up with a national plan that gets access money down to the local level in areas with inadequate state and county funding.
We won’t end HIV without national political will
This new PrEP program is an important step in the right direction, but unless political will and hard cash are harnessed to focus access to treatment, it’s going to be just one more half measure that fails to seize the moment and stop the epidemic in its tracks.
New York City (along with London and Amsterdam, internationally) has already shown us what we need to do. Within a few short years, HIV and its associated new infection treatment expense could become a thing of the past. Within a generation, HIV could be over, just a tragic historical footnote.