SEATTLE –To hear National Institute of Allergy and Infectious Diseases Director Anthony Fauci tell it, ending the AIDS epidemic in the U.S. is another one of those things that took 20 years to become an overnight sensation.
The plan made headlines when President Trump announced it as part of his State of the Union address on Feb. 5, followed by an editorial in the Journal of the American Medical Association by Fauci and colleagues from the CDC, the Health Resources & Services Administration, the Indian Health Service and the Department of Health & Human Services that began to flesh out the plan.
But "I've been trying to get this to get legs for quite a long time," Fauci told the audience at the opening session of the 2019 Conference on Retroviruses and Opportunistic Infections (CROI). "I have been talking and writing about this for well over a decade."
Even in the U.S., with its vast resources to bring to bear on the epidemic, the fight against the epidemic has stalled in important ways. Though the transformation of HIV infection from a death sentence to a chronic infection – a newly diagnosed 20-year-old can now expect to live for another half century – has been a medical miracle, there are still too many who need to benefit from that miracle.
There are an estimated 1.1 million HIV-positive individuals in the U.S., 15 percent of whom are unaware of their diagnosis.
And disturbingly, the rate of new infections is essentially flat at 38,000 annually.
But, Fauci said, the tools and the knowledge exist, to end the AIDS epidemic in its current form – "not eradicate, not eliminate, but end it as an epidemic phenomenon," he clarified.
By the numbers, that means reducing new HIV infections by 75 percent in five years, and by 90 percent in 10.
Those reductions have become possible with the success of treatment as prevention for infected individuals, and pre-exposure prophylaxis, or PrEP, for uninfected high-risk individuals.
In the PARTNER and PARTNER2 studies, tens of thousands of condomless sex acts led to no transmissions, demonstrating conclusively that "if you treat somebody that's infected, that person does not infect their sexual partner," Fauci said. "Undetectable really does mean untransmittable."
Likewise, studies have shown that consistent use of PrEP in the form of once-daily Truvada (emtricitabine/tenofovir disoproxil fumarate, Gilead Sciences Inc.) cuts the risk of HIV infection by more than 90 percent in high-risk individuals.
Location, location, location
In addition to those advances, Fauci said, an unrelated realization was key to his conviction that the epidemic can be ended.
That realization was that in the U.S., the epidemic is not only concentrated in certain demographic groups, it is also concentrated in certain geographic locations.
Of the 3,007 counties in U.S., 48 counties, the District of Columbia and Puerto Rico account for more than half of all new infections.
Not all the geographic hot spots are alike, which will complicate matters, Fauci acknowledged. In addition to coastal urban centers that are long-standing hot spots, there are also a number of rural counties in Southern states that are among the top geographic risk areas.
Rural locations, Fauci acknowledged, present unique challenges, as does the fact that the healthy young men who are at highest risk of HIV infection and would benefit most from PrEP are also the demographic group that is least likely to darken the doors of a medical care provider.
To address the geographic challenges, he said, "we put together a program that would utilize our Centers for AIDS Research," a group of 19 centers at different academic institutions. Located across the U.S., their overall locations match the geographic hot spots of the epidemic.
As for reaching high-risk individuals, he said, the outreach efforts that have worked in cities like San Francisco and Washington can be adapted to rural areas.
Bathhouses, gay bars and homeless shelters, which have been a focus of outreach in urban areas, exist in rural communities as well.
And there is at least one exception to the rule that healthy men in their 20s do not seek medical care unless they are gushing blood.
"People do go to STD clinics," he said, and "if you walk into an STD clinic and you don't have HIV, you should absolutely be on PrEP."
'More than treatment and prevention'
That Trump is the president who has taken up the banner to end the AIDS epidemic in the U.S. is somewhere between unexpected and ironic, as has been pointed out, among others, by the International AIDS Society (IAS).
"We applaud this commitment. However, we must also acknowledge that this announcement is inconsistent with the policies and rhetoric that directly attack trans people and the larger LGBTQ community, people who inject drugs, people of color, refugees, sex workers and women's rights," reads the IAS statement on President Trump's announcement of 10-year plan to end AIDS in the U.S., put out the day after the State of the Union. "Addressing these disparities will require more than treatment and prevention programs alone. For the U.S.'s new HIV strategy to succeed, Congress and the U.S. administration must examine the harmful policies and practices that reinforce stigma and social and gender injustice, including a ban on trans people in the military, and dismantling of public LGBTQ health and protection programs."
Fauci presented the key points of his talk at the opening press conference of the CROI meeting, where a reporter pointed out the same discrepancies during the question and answer session, and asked whether they would hinder implementation of the plan.
Fauci acknowledged that such concerns have been brought up repeatedly, and that given the actions of the current executive branch, how such concerns can arise is understandable.
But as he pointed out, "the people that are going to be implementing the program are not political people."
Fauci himself has served under five presidents, both Democratic and Republican. As a doctor, he also began caring for HIV-infected individuals in the earliest days of the pandemic, when life expectancy for a newly diagnosed HIV patient was one to two years, there were no treatments, and even the cause of AIDS was unknown.
Since that time, Fauci's commitment to fighting HIV has been unwavering. And once it was clear to him that the tools to ending the epidemic in the U.S. were not at hand, his argument became that using those tools was "almost a moral responsibility."