ELEMENTS FOR A NATIONAL STRATEGY ON REDUCING NEW HIV INFECTIONS

(Prepared with input from individual members of HIV Policy Working Group, HIV/AIDS Section, American Public Health Association, but not adopted as an APHA document; carried forward by the Beyond AIDS Foundation)

Non-highlighted text was approved in concept as a basis for further policy development, at the Annual Meeting of Beyond AIDS, 11/9/13. Additions in bold text and deletions in strikethrough have been proposed as update, 12/2/13. This draft is a work in progress, and should not be considered as final policy of Beyond AIDS.

For prevention of HIV infections, Beyond AIDS supports periodic updates to the 2010 National HIV/AIDS Strategy through progress reports, to integrate the concepts described in the President’s 2013 HIV Care Continuum Initiative. The next overall revision of the National AIDS Strategy (expected in 2015) should emphasize a central role for the care continuum, with the goals of achieving treatment as prevention as well as benefiting the health of persons living with HIV. This continuum, with public health enhancements as included in the outline below, should be promoted and supported with adequate public funding, and with a high emphasis on the rights, confidentiality, voluntary cooperation, and dignity of persons with HIV:

• Universal, routine, opt-out screening should be provided to adolescents and adults, as recommended by the Centers for Disease Control and Prevention (CDC), and by the U.S. Preventive Services Task Force (USPSTF). Screening methods and confirmation algorithms used should be selected from the latest recommended by CDC or by the National Institutes of Health (NIH).
• Risk assessment and effective prevention messages should be offered to all persons testing negative who can be accessed for such services, with availability of counseling, referrals, and repeat screening based on risk. Nucleic acid or antigen screening at the initial visit should be considered for those with very recent suspected exposure (such as partners of persons with detectable viral loads or persons who have very recently engaged in high risk sex), if these may detect early infections that have not yet produced antibodies.
•  Prompt and routine initial outreach services, consistently and adequately funded in all local jurisdictions nationwide, should be provided for all individuals confirmed as testing positive:

o   Linkage to care by healthcare providers who are knowledgeable about HIV management and prevention

o   Initial partner services by disease intervention or other public health specialists, or by properly trained healthcare personnel as permitted by law, to identify the most likely source partner and the most recently exposed partners, including confidential notification, counseling, and opt-out testing of possibly exposed individuals

• Maintenance of continuous HIV care, including integrated prevention measures, should be optimized by competent providers and support resources, including the following services:

o   Prompt offering and initiation of antiretroviral treatment, and assurance of continuous treatment availability, based on current guidelines and best practices

o   Proven strategies for maintaining tight adherence to antiretroviral regimens

o   Active community outreach to patients missing appointments, and closely tracked referrals to new sources of care for those who require a change in provider

o   Referrals to specialists, support groups, ADAP, case management cross-trained in prevention, substance abuse treatment, mental health services, housing, prevention with positives, and other programs (historically funded by the Ryan White CARE Act) as appropriate

o   Prevention messages fully incorporated into ongoing care and treatment, and provided with the best evidence-based approaches including:

o   Routine assessment and brief counseling during clinical visits, regarding sexual and drug-related behavior, with referrals as appropriate

o   Monitoring of treatment adherence, with simplification or adjustment of regimens as needed

o   Monitoring of viral load suppression, with resistance testing and adaptation of treatment when indicated, with the aim of achieving undetectable viral loads or lowest viral levels possible, to prevent transmission as well as the development of viral resistance

o   Use of surveillance data by public health departments to monitor adherence, retention, and viral suppression with follow-up that maintains strict confidentiality

o   Ongoing assessment about new partners, and referral (as above) or performance of follow-up partner services, including confidential notification, counseling, and opt-out testing for contacts

o   Other Prevention with Positives components, including accessible, available, and acceptable condom distribution; screening and treatment of other STDs, hepatitis B and C, and tuberculosis; prevention of mother-to-child transmission; reproductive health care; and referral to other services as needs arise during care

• Prophylactic use of antiretroviral medications by uninfected persons should gradually become less necessary with implementation of the above strategy.  and should be for clear and limited Its indications should be approved prioritized by CDC.  Pre-exposure prophylaxis should not be advocated as a substitute for condoms.  The efficacy of intra-exposure prophylaxis with various regimens for sero-negative partners of persons known to be infected and on treatment, e.g., if viral load is still detectable on treatment, or when condoms are refused or deferred to attempt pregnancy, should be intensively studied.

Beyond AIDS also supports population-based efforts to reduce risk-prone behaviors within high-risk communities. Such efforts include raising awareness of the issues surrounding HIV/AIDS, reducing stigma related to testing and treatment, mobilizing communities to take preventive actions, making condom distribution a structural intervention, and changing community norms about condom use.  These efforts also should incorporate prevention of other similarly-transmitted STDs and bloodborne pathogens (including hepatitis B and C), especially emphasizing the avoidance of unsafe sexual and drug/needle-related behavior. Education and screening should be utilized as an important means of detecting infected persons to initiate the HIV continuum of care.

For injection drug users, clean needles/syringes should be made available, including through pharmacies and private sector initiatives; but prevention of infections depends on keeping them clean and ultimately unused. Public health and other publicly funded efforts should emphasize disinfection and non-sharing of “works”; screening for HIV, hepatitis C, and hepatitis B; drug abuse prevention and treatment; education and counseling including group support; referrals as needed to health care, nutrition, and housing; and rehabilitation.

In the 2010 National HIV/AIDS Strategy, the three prevention steps were all targeted at populations (intensifying HIV prevention efforts in the communities where HIV is most heavily concentrated; expanding targeted efforts with evidence-based approaches, and educating all Americans about HIV and how to prevent it). While such efforts tend to be less efficient for prevention of HIV than the care continuum, which stops HIV transmission at the source, they remain valuable in preventing infection of persons unaware that they have HIV-infected partners, and in reducing transmission of other sexually transmitted diseases. Funding should be distributed to achieve the most cost-effective combinations and balances among such population-based strategies, and between them and the HIV care continuum.

Population-based programs should be culturally appropriate, and should include sexual health education across the lifespan. They should include efforts to change community norms relating to risk behaviors, which have proven to have high potential effectiveness, such as the A-B-C programs in Uganda and some other locations, and with community-level interventions in the US. All should utilize intensive outreach efforts and the use of social network referral programs and should emphasize screening, in order to initiate the care continuum as outlined above; including combined or coordinated screening for HIV and other similarly transmitted diseases.