Fauci: We Must Maximize Our Current Resources While Innovating to End HIV

“We find ourselves in a very unusual situation, and now is a good time for me to lay some common denominator principles that I think can be applicable to many, if not all, the countries beset with an HIV epidemic. Things will have to be modified for the different countries, but I hope you’ll see that the principles I’m laying out can really be extrapolated to the situation that many people throughout the world find themselves in,” said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, in a special live session on day 2 of AIDS 2020.

In “Ending HIV: Research Progress and Priorities,” which encompassed reducing the disparities underserved populations with HIV often face in their fight against the virus by brandishing new tools to fight those disparities and close the care gap, Fauci set the stage by laying bare several unsettling statistics:

• 14% of HIV-positive individuals do not know they are infected
• Close to 38,000 receive an HIV diagnosis each year
• Men who have sex with men (MSM), black/African American individuals, and Hispanic/Latino individuals shoulder a disproportionate burden of the disease

What tools do we need to fully address these numbers and end this HIV epidemic? Fauci said that first there must be a scientific basis for any plan, and that lies in (1) treatment, or the medications that are now available to treat both HIV and associated comorbidities (eg, protease inhibitors, integrase inhibitors, fusion/entry/postattachment inhibitors), and (2) prevention (eg, education/behavior modification, microbicides, condoms).

Thinking outside the box helps, too, and for that he talked about the importance of implementing “game-changers” centered around the idea that treatment equals prevention, which itself involves utilizing both treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP).

TasP involves suppressing viral loads such that “you make it virtually impossible for an individual to transmit that virus to their sexual partner, making it clear that undetectable actually does equal untransmissible in a scientifically sound way,” Fauci stated. And for PrEP, when taken as directed, it has an approximate 99% success rate in preventing HIV acquisition through sex.

Before implementing any plan or game-changers, however, it’s first necessary to address any apparent gaps that could hinder progress against HIV and AIDS, including those in the following areas:

• Testing
• Care retention
• Harm reduction services
• Food/housing security
• Human rights, including stigmatization

Defining an HIV vulnerability profile is also necessary, and this involves both demographic and geographic characteristics. In 2018, the latest year from which he presented data, Fauci detailed how even though black/African American people accounted for just 13% of the US population, 45% of new HIV diagnoses occurred among them, of whom 60% are MSM and of this subpopulation, 75% are younger than 35.

“We have a pretty well-defined demographic group that is bearing a disproportionate burden of our HIV in the United States,” Fauci said.

Geographically, 52% of all new HIV diagnoses occur in the South; in most years, more than 50% of new HIV infections occurred in 48 counties, Washington, DC, and Puerto Rico; and in 7 mostly southern states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, South Carolina), a majority of new infections occur in rural areas.

What does this all mean? It’s necessary to collect and disseminate data that link both fundamental science and innovative science to effective approaches to inform interventions to end the HIV epidemic at the community level.

To this end, Centers for AIDS Research at the National Institutes of Health contribute by providing shared research support; stimulating scientific collaboration; supporting basic, translational, implementation, and health policy research; and supporting research on HIV prevention and treatment to patient subpopulations who typically are the victims of care disparities, “because for so long, they were really not linked into the main flow of tests,” Fauci noted.

“The key is to optimize the HIV prevention and treatment toolkit in 2 ways,” he emphasized. “You maximize the implementation of what you have and you develop new and improved tools that address both treatment and prevention.”