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Are We Actually 10 Years From the End of HIV?

10 years from the cure

Can a well-meaning CDC director override a hostile administration and deliver an end of the HIV epidemic within a decade?

When it was announced earlier this year, Trump’s plan to end the HIV epidemic within a decade was met with mixed reviews. Heralded for good intentions, many advocates and policy makers still questioned its strategy (and the commitment of an administration that remains determined to dismantle the Affordable Care Act, which has had demonstrable positive impacts on slowing the epidemic and improving the lives of those living with HIV).

But Dr. Robert Redfield, director of the Centers for Disease Control and Prevention insists, “It is a realistic plan. We’re in this to do it. We’re in this to get it done. This should not be equated with some pronouncement like we heard many years ago about the war on cancer or the war on poverty. This is an intentional program to build the important tools that have been developed.”

As confident as Redfield is in the administration’s commitment, it will take time for many to be convinced. After all, in the two years since Trump took office, his administration continues to threaten access to health care, frequently undermines social services poz people rely on, and attacks the very scientific research that must underpin any effort to successfully address the complex issues (and social disparities) that continue to drive this epidemic.

Redfield, himself a Trump appointee, stands behind the plan to reduce new diagnoses by 75 percent within five years, and 90 percent within 10 years. He says it starts in jurisdictions like Washington, D.C., and San Juan, Puerto Rico, where “over 50 percent of new diagnoses occurred in 2016 and 2017.”

In a nutshell, the new plan will alter the way money is allocated, directing resources to the locations that represent the highest number of new diagnoses. In other words, it will build programs to deliver treatment and care to where the people are — rather than having people travel to where the treatment was. Redfield explains that making this change is going to “require innovation in care delivery systems,” specifically on the local end. “Concentrating resources and allowing [at-risk] communities to develop their own individual community plans,” rather than having “a set plan for everybody” is a key focus moving forward.

“Some areas may find out that what they need is more expansion of, say, syringe programs,” Redfield explains, applauding the state of Georgia’s recent passing of the HB 217, a law that legalized needle exchange programs.

“Other areas may find what they need is more innovative ways to deliver PrEP in nonclinical settings,” he adds. “Another area may find they just don’t have a clinical space that transgender persons feel comfortable in, and they have to figure out how to create it… Each community is going to have to figure that out. This is not a program designed to implement a specific medical approach. This is a program that’s designed to bring new HIV infections to an end.”

To ensure these efforts, the CDC plans on asking the people directly. “What we will be doing as part of the planning process is really asking each of the communities to identify what they consider to be key structural challenges that prevent them from doing the work they need to get done,” Eugene McCray, director of HIV/AIDS prevention at the CDC, explains. “In some cases, it might be just changing a policy or procedure that could make things work better. So we want to identify all of those, and then work with the community to really address it.”

Working closely with at-risk communities to best address local needs may indeed help address the HIV epidemic, but activists point out that another, perhaps even more effective effort involves improving access to PrEP.

And that raises significant questions about how the CDC has dealt with Truvada, currently the only drug the FDA has approved for use as PrEP. The Washington Post reported in March this year that, since 2015, the CDC has owned the patent for Truvada, but hasn’t requested any royalties from Gilead, which manufacturers the antiretroviral medication. Given that the pharmaceutical giant raked in over $1 billion last year from Truvada alone, the CDC could have invested millions (or even hundreds of millions) of dollars over the past five years back into the prevention of or treatment of HIV. (At a Congressional oversight hearing this spring, Gilead’s CEO, Daniel O’Day, insisted that the federal government’s patent on the drug isn’t valid.)

While speaking at this year’s AIDS Watch in D.C., Redfield was jeered by activists following the Washington Post report. “Obviously, I would’ve rather not been heckled,” Redfield says now. “But we’re serious about engaging the community. In order to do that, we have to show up, and interact, and I wanted to hear from the community. It doesn’t mean I have to hear everything. I want to hear what the community says, and I heard them. And I hope people respected the fact that I was there to hear from the community.”

Some of what he heard was that for many people high drug costs are one of the biggest barriers limiting access to treatment. “People are really striving to try figure out how to solve” the issue of drug inflation, Redfield says. “We’re all trying to do the same thing.”

Another issue he’s trying to solve is how to extinguish HIV outbreaks in early stages, and he thinks the answer may lie in new innovations in delivery systems—and in getting more services involved early. “We need to help the public health community—and more importantly, the community where those clusters are occurring — to understand when interventions need to be augmented to be able to bring those clusters to an end. And ultimately, this is going to be done by developing a much more robust HIV workforce.”

That workforce includes an increase in public health types, as well as “more encouragement” in the broader health community — including from social workers, providers, and nurses. “It’s a program that I anticipate will have 57 different plans,” he says, referring back to the administration’s initiative. “We’re looking forward to the communities working together over the next several months ahead to begin to put together what they think is an [appropriate] plan.”

Though the plan to virtually eradicate HIV in the next 10 years seems like a stretch, Redfield says we should all be excited for the research currently in place in regard to functional cures “where people can maintain bio-suppression, independent of antiretrovirals… I think you’re going to see more and more progress in that area.”

“There’s a lot of movement in the pharmaceutical industry to make long-acting drugs that will allow people different options to be able to maintain it, both for treatment and prevention,” he adds. “And I do think there’s going to be advancement in allowing people access to diagnostics in nonclinical settings, which will improve it.”

“Long-acting preparations,” McCray chimes in, “like an injection you can take once every six months, would be great both for prevention and treatment. And then, of course, point of care diagnostics to ensure that we’re getting diagnostics to rural areas and to communities that don’t have access to a clinic and so forth. Home testing is one example. But also, having finger stick technology where you can do a blood spot and get it done.”

Ending new HIV transmissions in the U.S. within a decade seems a high bar to reach, particularly given this administration’s ongoing efforts to undermine the health and wellbeing of the very communities most at risk of becoming HIV-positive (including African Americans, gay and bi men, undocumented immigrants, and transgender people). But one cannot doubt Redfield’s personal commitment to the cause.

“I started my career in 1980 and was full-time in HIV from ‘83 on,” he recalls. “There’s a lot of us that have been in the arena for a long time who have no intention other than succeeding. And we’re going to only succeed if we have the full engagement and the leadership of the community as the key partner.”

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