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Behavioral Factors in Assessing Impact of HIV Treatment as Prevention

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Abstract

The recent NIH HPTN 052 study of using HIV treatment to prevent HIV transmission in serostatus discordant heterosexual partnerships has garnered much attention. In subsequent discussions, however, the topic of HIV-related risk behavior has been nearly absent. Here, we identify the critical roles that HIV-related risk behavior plays in determining the unmet needs, optimal targeting, and ultimate impact of treatment as prevention. We describe the size of the population at risk of HIV and three subgroups of persons living with HIV (PLWH) based on awareness of serostatus and risk behavior, and the corresponding HIV transmission rates to seronegative partners. For each of the subgroups of PLWH, we identify which approach is most relevant (“testing and linkage to care,” “treatment as prevention,” and/or “treatment as clinical care”). We observe that the impact of “treatment as prevention” on HIV incidence will depend heavily on which subgroup of PLWH is targeted for services.

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References

  1. The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States. Washington D.C.: White House; 2010.

  2. Cohen MS, Chen YQ, McCauley M. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.

    Article  PubMed  CAS  Google Scholar 

  3. Cohen J. Breakthrough of the year: HIV treatment as prevention. Science. 2011;334(6063):1628.

    Google Scholar 

  4. Clinton HR. Address on global HIV/AIDS. National Institutes of Health, Bethesda. 2011. http://videocast.nih.gov/summary.asp?live=10787. Accessed 5 Mar 2012.

  5. Obama B. Keynote address for world AIDS day. George Washington University, Washington, DC. 2011. http://www.whitehouse.gov/photos-and-video/video/2011/12/01/president-obama-world-aids-day. Accessed 5 Mar 2012.

  6. Kawata P. NMAC’s big audacious goal: world AIDS day 2011. National Minority AIDS Council. 2011. http://www.nmac.org/component/content/article/52-headlines/1278-nmacs-big-audacious-goal-world-aids-day-2011.pdf. Accessed 5 Mar 2012.

  7. Strub S. Prevention vs. prosecution: creating a viral underclass. POZ blogs. 2011. http://blogs.poz.com/sean/archives/2011/10/prevention_vs_prosec.html. Accessed 5 Mar 2012.

  8. Kawata P. Opening plenary speech for national HIV prevention conference. Centers for Disease Control and Prevention, Atlanta. 2011. http://drcnet.org/pipermail/harmred/2011-August/000532.html. Accessed 5 Mar 2012.

  9. Shelton JD. HIV/AIDS ARVs as HIV prevention: a tough road to wide impact. Science. 2011;334(6063):1645–6.

    Article  PubMed  CAS  Google Scholar 

  10. Cambiano V, Rodger AJ, Phillips AN. Test-and-treat’: The end of the HIV epidemic? Curr Opin Infect Dis. 2011;24(1):19–26.

    Article  PubMed  Google Scholar 

  11. Pence BW, Mugavero MJ, Carter TJ, et al. Childhood trauma and health outcomes in HIV-infected patients: an exploration of causal pathways. J Acquir Immune Defic Syndr. 2011 (Epub ahead of print).

  12. Hogan CM, Degruttola V, Sun X, et al. The setpoint study (ACTG A5217): effect of immediate versus deferred antiretroviral therapy on virologic set point in recently HIV-1-infected individuals. J Infect Dis. 2012;205(1):87–96.

    Article  PubMed  CAS  Google Scholar 

  13. Hasse B, Ledergerber B, Hirschel B, et al. Frequency and determinants of unprotected sex among HIV-infected persons: the Swiss HIV cohort study. Clin Infect Dis. 2010;51(11):1314–22.

    Article  PubMed  Google Scholar 

  14. Heijman T, Geskus RB, Davidovich U, Coutinho RA, Prins M, Stolte IG. Less decrease in risk behaviour from pre-HIV to post-HIV seroconversion among MSM in the combination antiretroviral therapy era compared with the pre-combination antiretroviral therapy era. AIDS. 2012;26(4):489–95.

    Article  PubMed  Google Scholar 

  15. Nakagawa F, Lodwick RK, Smith CJ, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS. 2012;26(3):335–43.

    Article  PubMed  Google Scholar 

  16. Novitsky V, Essex M. Using HIV viral load to guide treatment-for-prevention interventions. Curr Opin HIV AIDS. 2012;7(2):117–24.

    Article  PubMed  CAS  Google Scholar 

  17. Marks G, Gardner LI, Craw J, Crepaz N. Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis. AIDS. 2010;24(17):2665–78.

    Article  PubMed  Google Scholar 

  18. Attia S, Egger M, Müller M, Zwahlen M, Low N. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS. 2009;23(11):1397–404.

    Article  PubMed  Google Scholar 

  19. Forsyth AD, Valdiserri RO. Reaping the prevention benefits of highly active antiretroviral treatment: policy implications of HIV prevention trials network 052. Curr Opin HIV AIDS. 2012;7(2):111–6.

    Article  PubMed  CAS  Google Scholar 

  20. Garnett GP, Becker S, Bertozzi S. Treatment as prevention: translating efficacy trial results to population effectiveness. Curr Opin HIV AIDS. 2012;7(2):157–63.

    Article  PubMed  CAS  Google Scholar 

  21. Wood E, Milloy MJ, Montaner JSG. HIV treatment as prevention among injection drug users. Curr Opin HIV AIDS. 2012;7(2):151–6.

    Article  PubMed  CAS  Google Scholar 

  22. Mayer KH. Antiretrovirals for HIV prevention: translating promise into praxis. Lancet. 2011;378:206–7.

    Article  PubMed  Google Scholar 

  23. Nattrass N. Expanding an AIDS intervention to include HAART for all who need it. In: Nattrass N, editor. The moral economy of AIDS in South Africa. Cambridge: Cambridge University Press; 2004. p. 99–131.

    Google Scholar 

  24. Presidential Advisory Council on HIV/AIDS. Letter to Secretary of the Department of Health and Human Services Kathleen Sebelius. 2011. http://aids.gov/federal-resources/policies/pacha/policy-pacha/. Accessed 5 Mar 2012.

  25. Presidential Advisory Council on HIV/AIDS. Letter to President Barack Obama. 2011. http://aids.gov/federal-resources/policies/pacha/policy-pacha/. Accessed 5 Mar 2012.

  26. National Alliance of State & Territorial AIDS Directors (NASTAD). ADAP Watch. 2012. http://www.nastad.org/Docs/011223_ADAP%20Watch%20update%20-%204.6.12.pdf. Accessed 6 Apr 2012.

  27. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793–800.

    Article  PubMed  Google Scholar 

  28. CDC. Vital signs: HIV prevention through care and treatment––United States. MMWR. 2011;60:1618–1623.

  29. Hall HI, Gray KM, Tang T, Li J, Shouse L, Mermin J. Retention in care of adults and adolescents living with HIV in 13 U.S. Areas. J Acquir Immune Defic Syndr. 2012 (Epub ahead of print).

  30. Giordano TP, Gifford AL, White AC Jr, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007;44:1493–9.

    Article  PubMed  Google Scholar 

  31. Mugavero MJ, Davila JA, Nevin CR, et al. From access to engagement: measuring retention in outpatient HIV clinical care. AIDS Patient Care STDs. 2010;24:607–13.

    Article  PubMed  Google Scholar 

  32. Mugavero MJ, Lin H-Y, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009;48(2):248–56.

    Article  PubMed  Google Scholar 

  33. Ulett KB, Willig JH, Lin H-Y, et al. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care and STDs. 2009;23:41–9.

    Article  PubMed  Google Scholar 

  34. Aberg JA, Kaplan JE, Libman H, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:651–81.

    Article  PubMed  Google Scholar 

  35. Institute of Medicine of the National Academies. Public financing and delivery of HIV/AIDS care: securing the legacy of Ryan White. The National Academies Press, Washington, DC; 2004.

  36. CDC. Questions and answers: HIV transmission. 2010. http://www.cdc.gov/hiv/resources/qa/transmission.htm. Accessed 6 Apr 2012.

  37. CDC. HIV surveillance report, 2009, vol 21. 2011. http://www.cdc.gov/hiv/surveillance/resources/reports/2009report/index.htm. Accessed 5 Mar 2012.

  38. Prejean J, Song R, Hernandez A, Ziebell R, Green T, Walker F, Lin LS, An Q, Mermin J, Lansky A, Hall HI. HIV Incidence Surveillance Group. Estimated HIV incidence in the United States, 2006–2009. PLoS ONE. 2011;6(8):e17502.

  39. Hughes JP, Baeten JM, Lingappa JR, et al. Determinants of Per-Coital-Act HIV-1 infectivity among African HIV-1-Serodiscordant couples. J Infect Dis. 2012;205(3):358–65.

    Article  PubMed  CAS  Google Scholar 

  40. Holtgrave DR, McGuire JF, Milan J Jr. The magnitude of key HIV prevention challenges in the United States: implications for a new national HIV prevention plan. Am J Public Health. 2007;97(7):1163–7.

    Article  PubMed  Google Scholar 

  41. Janssen RS, Holtgrave DR, Valdiserri RO, Shepherd M, Gayle HD, De Cock KM. The serostatus approach to fighting the HIV epidemic: prevention strategies for infected individuals. Am J Public Health. 2001;91(7):1019–24.

    Article  PubMed  CAS  Google Scholar 

  42. CDC. HIV surveillance—United States, 1981–2008. MMWR. 2011;60:689–693.

  43. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39(4):446–53.

    Article  PubMed  Google Scholar 

  44. Hall HI, Holtgrave DR, Maulsby C. HIV transmission rates from persons living with HIV who are aware and unaware of their infection, United States. AIDS. 2012 (Epub ahead of print).

  45. Hall HI, Green TA, Wolitski RJ, et al. Estimated future HIV prevalence, incidence, and potential infections averted in the United States: a multiple scenario analysis. J Acquir Immune Defic Syndr. 2010;55(2):271–6.

    Article  PubMed  Google Scholar 

  46. Holtgrave D, Hall HI, Rhodes PH, Wolitski R. Updated annual HIV transmission rates in the United States, 1977–2006. J Acquir Immune Defic Syndr. 2009;50(2):236–8.

    Article  PubMed  Google Scholar 

  47. Metsch LR, Pereyra M, Messinger S, et al. HIV transmission risk behaviors among HIV-infected persons who are successfully linked to care. Clin Infect Dis. 2008;47:577–84.

    Article  PubMed  Google Scholar 

  48. Kalichman SC, Rompa D, Cage M. Group intervention to reduce HIV transmission risk behavior among persons living with HIV/AIDS. Behav Modif. 2005;29:256–85.

    Article  PubMed  Google Scholar 

  49. Freedman M, Mattson C, Johnson C, et al. Medical monitoring project, 2009–2010. National representative estimates of sexual risk behaviors among HIV+ adults receiving medical care: US 19th conference on retroviruses and opportunistic infections. Seattle, Washington. 2012.

  50. Sorenson SW, Sansom SL, Brooks JT, et al. A mathematical model of comprehensive test-and-treat services and HIV incidence among men who have sex with men in the United States. PLoS ONE. 2012;7(2):e29098.

    Article  Google Scholar 

  51. Van Gorder, D. Can HIV testing plus linking HIV+ people to care and treatment reduce HIV transmission? Project Inform fact sheet. University of California, Center for AIDS Prevention Studies, San Francisco. 2010. http://www.projectinform.org/pdf/tlc_caps.pdf. Accessed 5 Mar 2012.

  52. Golden MR, Brewer DD, Kurth A, Holmes KK, Handsfield HH. Importance of sex partner HIV status in HIV risk assessment among men who have sex with men. J Acquir Immune Defic Syndr. 2004;36:734–42.

    Article  PubMed  Google Scholar 

  53. CDC. High-impact HIV prevention CDC’s approach to reducing HIV infections in the United States. 2011. http://www.cdc.gov/hiv/strategy/dhap/pdf/nhas_booklet.pdf. Accessed 5 Mar 2012.

  54. Holtgrave DR. Costs and consequences of the US Centers for Disease Control and Prevention’s recommendations for opt-out HIV testing. PLoS Med. 2007;4(6):e194.

    Article  PubMed  Google Scholar 

  55. Farnham PG, Sansom SL, Hutchinson AB. How much should we pay for a new HIV diagnosis? A mathematical model of HIV screening in US clinical settings. Med Decis Making. 2012 (Epub ahead of print).

  56. Gardner LI, Metsch LR, Anderson-Mahoney P, et al. Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS. 2005;19(4):423–31.

    Article  PubMed  Google Scholar 

  57. Schackman BR, Leff JA, Botsko M, et al. The cost of integrated HIV care and buprenorphine/naloxone treatment: results of a cross-site evaluation. J Acquir Immune Defic Syndr. 2011;56(Suppl 1):S76–82.

    PubMed  Google Scholar 

  58. Holtgrave DR, Briddell K, Little E, et al. Cost and threshold analysis of housing as an HIV prevention intervention. AIDS Behav. 2007;11(6 Suppl):162–6.

    Article  PubMed  Google Scholar 

  59. Holtgrave DR, Pinkerton SD, Jones TS, Lurie P, Vlahov D. Cost and cost-effectiveness of increasing access to sterile syringes and needles as an HIV prevention intervention in the United States. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(Suppl 1):S133–8.

    Article  PubMed  Google Scholar 

  60. Walensky RP, Freedberg KA, Weinstein MC, Paltiel AD. Cost-effectiveness of HIV testing and treatment in the United States. Clin Infect Dis. 2007;45(Suppl 4):S248–54.

    Article  PubMed  Google Scholar 

  61. Trentacoste ND, Holtgrave, Collins C, Abdul-Quader A. Disseminating effective behavioral interventions for HIV prevention: a cost analysis of a risk-reduction intervention for drug users. J Public Health Manag Pract. 2004;10(2):130–9.

    PubMed  Google Scholar 

  62. Wagner BG, Kahn JS, Blower S. Should we try to eliminate HIV epidemics by using a ‘Test and Treat’ strategy? AIDS. 2010;24(5):775–6.

    Article  PubMed  Google Scholar 

  63. Sanders GD, Anaya HD, Asch S, Hoang T, Golden JF, Bayoumi AM, Owens DK. Cost-effectiveness of strategies to improve HIV testing and receipt of results: economic analysis of a randomized controlled trial. J Gen Intern Med. 2010;25(6):556–63.

    Article  PubMed  Google Scholar 

  64. Holtgrave DR. Potential and limitations of a ‘test and treat’ strategy as HIV prevention in the United States. Int J Clin Pract. 2010;64(6):678–81.

    Article  PubMed  CAS  Google Scholar 

  65. Pinkerton SD, Pearson CR, Eachus SR, Berg KM, Grimes RM. Proposal for the development of a standardized protocol for assessing the economic costs of HIV prevention interventions. J Acquir Immune Defic Syndr. 2008;47(Suppl 1):S10–4.

    PubMed  Google Scholar 

  66. Walensky RP, Paltiel AD, Losina E, et al. Test and treat DC: forecasting the impact of a comprehensive HIV strategy in Washington DC. Clin Infect Dis. 2010;51(4):392–400.

    Article  PubMed  Google Scholar 

  67. Walensky RP. Cost-effectiveness of HIV interventions: from cohort studies and clinical trials to policy. Top HIV Med. 2009;17(4):130–4.

    PubMed  Google Scholar 

  68. Hornberger J, Holodniy M, Robertus K, Winnike M, Gibson E, Verhulst E. A systematic review of cost-utility analyses in HIV/AIDS: implications for public policy. Med Decis Mak. 2007;27(6):789–821.

    Article  Google Scholar 

  69. Marseille E, Shade SB, Myers J, Morin S. The cost-effectiveness of HIV prevention interventions for HIV-infected patients seen in clinical settings. J Acquir Immune Defic Syndr. 2011;56:e87–94.

    Article  PubMed  Google Scholar 

  70. Shresta RK, Begley EB, Hutchinson AB, et al. Costs and effectiveness of partner counseling and referral services with rapid testing for HIV in Colorado and Louisiana, United States. Sex Transm Dis. 2009;36:637–41.

    Article  Google Scholar 

  71. Merson M, Padian N, Coates TJ, et al. Combination HIV prevention. Lancet. 2008;372(9652):1805–6.

    Article  PubMed  Google Scholar 

  72. Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet. 2008;372(9639):669–84.

    Article  PubMed  Google Scholar 

  73. UNAIDS. Combination HIV prevention: tailoring and coordinating biomedical, behavioural and structural strategies to reduce new HIV infections. 2010. http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20111110_JC2007_Combination_Prevention_paper_en.pdf. Accessed 5 Mar 2012.

  74. Small W, Kerr T. HIV treatment as prevention and the role of applied social science research. J AIDS Clin Res. 2011;2:102e. doi:10.4172/2155-5133.1000102e.

    Google Scholar 

  75. American Psychological Association. Resolution on combination and behavioral approaches to optimize HIV prevention, Washington D.C. 2011. http://www.apa.org/pi/aids/resources/resolutions.aspx?item=2. Accessed 5 Mar 2012.

  76. U.S. Census Bureau, population estimates. 2009. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=PEP_2009_T01&prodType=table. Accessed 5 Mar 2012.

  77. Chandra A, Billioux V, Copen C. National Center for Health Statistics; Sionean, Catlainn, National Center for HIV/AIDS, Viral Hepititis, STD, and TB prevention. HIV risk-related behaviors in the united states household population aged 15–44 years: data from the national survey of family growth, 2002 and 2006–2010. National Health Statistics Report 2012;46. Accessed Mar 5 2012.

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This manuscript was prepared as part of Government work (HIH) and there are no other funding sources to declare (DRH, CM, LW)

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The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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Holtgrave, D.R., Maulsby, C., Wehrmeyer, L. et al. Behavioral Factors in Assessing Impact of HIV Treatment as Prevention. AIDS Behav 16, 1085–1091 (2012). https://doi.org/10.1007/s10461-012-0186-1

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