Ronald P. Hattis, MD, MPH, Secretary and Past-President
There are mixed effects from communicating virtually (Zoom, Gotomeeting, etc.) and by email, rather than in person, with national and state public health leaders. On the one hand, it has saved us money that we would have needed to spend for travel to Washington, Sacramento, and New York, etc. On the other hand, not meeting in person makes it more difficult to establish the interpersonal connections that can be very helpful to sway thinking and influence public policy.
In the last few months, our Beyond AIDS Foundation (BAF) has remotely submitted input for the 2021-2025 National HIV/AIDS Strategy, which was not incorporated into the final plan, but which we are still promoting as activities to optimally implement it. I also provided public comment on March 9, 2021 on behalf or BAF to the Presidential Advisory Council on HIV/AIDS (PACHA), which reintroduced our organization to PACHA (on which two of our Board members had previously served), but did not result in any immediate action. For both of these initiatives, we made reference to the findings and recommendations of our published survey of state and territorial HIV/AIDS Directors, in which we had found much inconsistency and some missed opportunities to enhance the HIV Care Continuum (HCC).
The HCC refers to the various stages that patients have to move through before the HIV virus can be suppressed to undetectable levels, resulting in almost no sexual transmission. Those stages include screening to diagnose infected persons, linking infected (HIV positive) persons to care, initiating antiviral treatment immediately or as soon as possible, retaining treated patients in care, and suppressing the "viral load." There is dropout at each stage, and a major pubic health objective is to reduce the dropout rates so that the vast majority of patients can reach the ultimate goal of viral suppression, and consequently not passing the virus on to others. The concept is sometimes called "treatment as prevention," something to which I have a strong personal commitment, as one of the first people to advocate it, back in 1996. It was eventually adopted as a cornerstone of US HIV strategy, but not until 15 years later.
Beyond AIDS Foundation specifically advocates that state and local public health staff reach out to patients and providers as soon as a new positive HIV test is reported, to urge and help arrange linkage to a source of HIV care, to perform or arrange for partner services (contact tracing and partner notification). and to discuss other relevant concerns. In our survey, we found that most jurisdictions did this, but that some were not doing so routinely. We also advocate that public health departments keep track of a specific reportable HIV test, the viral load, which measures virus in the blood. If test results show high levels of virus that are not dropping, we suggest that providers be contacted to see whether anything can be done to assist. If no viral load tests are reported for a year, there should also be outreach to find out whether the patient has dropped out of care or moved to another jurisdiction, either of which deserves follow-up. Over 40% of jurisdictions had on their own initiative started looking for such "missed viral load results" in diagnosed persons, even though CDC had not required this. We think that this practice should become universal and an expectation of CDC. When medical appointments for HIV patients are missed, providers should be expected to reach out to patients to persuade them to make new appointments, and if are no longer reachable, public health should be notified.
We also recommend that all states and territories make genotype results, which indicate whether the virus is sensitive or resistant to various medications, reportable to public health. In our survey, in 62% of jurisdictions these were not reportable. We also recommend that genotype results, or aggregate summaries, be forwarded to CDC so that there can be full national surveillance for the emergency of resistant strains. We also found that 28% of states and territories were relying entirely on CDC grants for HIV prevention. CDC money will often be the biggest source of funding for HIV prevention, but is usually not sufficient by itself, and should be supplemented by additional funding raised by states, local jurisdictions, and/or private sources.
Upcoming is another opportunity for our Foundation to capture the attention of some key federal public health leaders. We plan a brief BAF presentation during the public comment period at the April 20, 2021 meeting of CHAC, an advisory committee to CDC (Centers for Disease Control and Prevention) and HRSA (Health Resources and Services Administration) regarding HIV, STDs, and viral hepatitis programs. This may be our most important interaction with federal personnel, because most of the recommendations of our survey article were for CDC and to a lesser extent HRSA to consider some changes to what is expected in return for their grants.
Internally, this year we will be updating our Foundation's objectives and declarations, which are over a decade old. We will also be looking for opportunities for involvement "beyond AIDS." As the pandemic diverts staff from control of sexually transmitted infections, rates of some of those infections have risen, and there is a risk that HIV infections may as well. Ongoing prevention and control efforts for all these diseases should not suffer as the pandemic progresses into its second year.
