Population Improvement Strategy for Prevention and Treatment of HIV

Background of HIV/AIDS
Human immunodeficiency virus (HIV) pandemic remains a prevalent public health crisis both globally and in the United States. The world statistics estimate for HIV was 37 Million people by 2016 with 1.8 Million new cases reported in 2017. HIV is disproportionately high in Sub-Saharan Africa accounting for 66% of new infections worldwide. The CDC reports that of the 36.9 Million patients, 21.7 Million people are under antiretroviral therapy (ART). CDC estimates 1.1 million people were living with HIV in the US by end of 2016 with 14% of the population unaware that they were living with HIV. The Center for Disease Control and Prevention (CDC) estimates that over 700,000 have succumbed to HIV/AIDS since the recognition of the virus in 1981. US HIV statistics are varied across gender, gender identity, race, and region. While the pandemic is highly prevalent among the young aged 25-34, the HIV statistics are proportionately higher in bisexual and gay men accounting for 66% of all HIV diagnoses in 2017. The African Americans and the Hispanic community have the highest prevalence of HIV accounting for 43% and 26% of HIV diagnoses respectively. HIV is prevalent in the urban areas with the South recording the highest absolute numbers of HIV cases (52% of new HIV diagnoses in 2017), the Northeast reporting the highest rates of HIV and the Midwest reporting the least cases of HIV(CDC, 2019). While the US National HIV/AIDS Strategy 2020 seeks to reduce the burden of HIV and AIDs, the chronic diseases remain a constraint to public health.
HIV is a virus that progressively destroys infection-disease fighting CD4 cells subsequently weakening the body immune system. Untreated HIV infection advances to Acquired Immune Deficiency Syndrome (AIDS). There exist two genetically distinct viruses; HIV-1 and HIV-2, with HIV-1 being the prevalent type with over 60 known strains. The virus is spread through contact with contaminated semen, rectal fluids, pre-seminal fluids, vaginal fluids, blood or breast milk. HIV is transmitted through unprotected vaginal or oral sex, sharing of non-sterilized injection equipment or mother to bather infection through pregnancy, birth or breastfeeding, blood transfusion, and organ transplant. The transmission occurs only if mucous membrane or damaged tissue is in contact with contaminated fluids or if the fluids are injected directly to the bloodstream. There exist myths and misinformation on other possible transmission mechanisms such as handshake, hugs kisses, sharing of dishes, doorknobs and toilet seats with people with the virus, pets, and insects. Such misconception manifest into existing social stigmatization of HIV and marginalization of HIV victims. The CDC (2019) reports that roughly 1 in 8 HIV patients do not access health care services due to discrimination and HIV stigma.
Landmark scientific and biomedical research advances have resulted in the development of prevention strategies, treatment options and improved care for HIV patients (Fauci, et al., 2019). A combination of biomedical; behavioral and structural interventions provides a holistic approach in HIV management. The advances in HIV treatment has considerably narrowed the life expectancy gap between people living with HIV virus and accessing quality treatment and HIV-uninfected individuals (Marcus et al., 2017). Fundamentally, HIV prevention strategies such as abstinence, use of condoms, limited sexual partners and HIV prevention medicines such as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) are the advisable approaches of preventing HIV infection. Currently, there exist no commercially available curable treatments or vaccines for HIV, hence the antiviral treatment is administered to suppress the viral loads.
Antiviral treatments are administered for managing HIV associated morbidity and prevention of further transmission. Introduced in the late 20th century, Antiretroviral therapy (ART) which is a combination of medicine accounts as the primary treatment option for prolonging viral suppression and restoring the immune system. While ART doesn’t cure HIV, it prevents the multiplication of HIV virus reducing the viral load to undetectable viral load which reduces the risk of transmission. The Department of Health and Human Services (DHHS) outlines that ART should be introduced CD4 count below 350/µL. However, DHHS recommends immediate introduction of ART for pregnant, or hepatitis B virus (HBV) or HIV-associated nephropathy patients irrespective of the CD4 count. ART is administered in combination of three HIV medicines derived from two varied drug classes out of the seven possible classes; protease inhibitors (PIs); nucleoside reverse transcriptase inhibitors (NRTIs); CCR5 antagonists, post-attachment inhibitors, non-nucleoside reverse transcriptase inhibitors (NNRTIs); integrase strand transfer inhibitors (INSTIs); and fusion inhibitors (Cihlar & Fordyce, 2016). Nurses are the primary caregivers so they play a forefront role in HIV treatment improvement and HIV prevention. The role or nurses transcends beyond the bedside care to integrating innovation behavioral approaches that increase rapid HIV testing and ART adherence. Spaulding et al. (2016) identify that higher rates of HIV screening initiated by nurses as opposed to physician demonstrating the nurse's fundamental role in HIV management. Nurses provide both critical medical and psychological care necessary in diminishing the existing HIV stigmatization.
Population Improvement Plan for Treatment and Prevention of HIV
a. Early Diagnoses of HIV
Shah et al. (2016) propose three initiatives that are fundamental in improvement plans for treating and preventing HIV transmission; early diagnosis; ART initiation and care retention, and prevention of transmission to risk groups. Early diagnosis of HIV is the foundation of early treatment and minimized transmission (Shah, et al., 2016). HIV diagnosis is done through a test such as ELISA test; Saliva test, Viral Load test; and Western Blot test. Delayed diagnoses of HIV complicates the prevention of transmission and management of HIV pausing a substantial health care implication. Dailey et al. (2017) estimate that 40% of new HIV transmission in the US are from people unaware of having HIV. The study further identifies delayed diagnoses with a median interval of 3 years between infection and diagnosis. Early diagnoses enable the HIV infected person to enter in ART care which enables lowering of viral load and prevention of transmission. Dailey et al. Shah,et al. (2016) estimates that early HIV screening and linkage to care would yield a 20-25% decline in HIV mortality burden while enhancing the cost-effectiveness of managing HIV in the US (2017) analysis of the dynamics of HIV diagnosis in the US identifies higher prevalence of testing among females relative to males, black ethnicity relative to other races among other categories. The study findings demonstrate gaps in HIV testing in the US and the need for differentiated initiatives in promoting diagnosis among the different social groups in the US.
Over the years, Community Health Workers (CHW) have become increasingly integrated into the health care setting and mainly in the management of chronic conditions. CHW is a fundamental group in promoting the uptake of HIV testing since they are respected lay members of the community. CHW engage with the local community in diverse setting including local church or local market which provides avenues for awareness initiatives. CHW addresses a fundamental health care challenge –limited health care resources- reducing the economic burden of managing HIV. HIV testing approach has predominantly followed the voluntary counseling and testing (VCT) approach mainly undertaken at health care centers. However innovative approaches are emerging that are increasing uptake of testing. Advancement on testing kits has made HIV testing convenient. Approval of rapid testing kits such as OraQuick (home-based HIV rapid testing (HBHRT) kit) by the Food and Drug Administration (FDA) increases the uptake of HIV testing in High-risk groups. Engaging Community Health Workers (CHW) in promoting the use of HBHRT) kit one of the community level approaches of increasing the uptake of HIV testing. Wallace, et al. (2019) proposes CHW facilitated rapid testing in cultural distinctive African American neighborhood. Wallace, et al. (2019) argues that the CHWs could effectively address HIV misconceptions and HIV screening behaviors.
b. ART Treatment Adherence
Treatment to prevent transmission of HIV is the cornerstone of controlling HIV in the US. Untreated HIV gradually destroys CD4 cells and progresses to AIDs which occurs when the CD4 count drops below 200 for HIV infected person. As well untreated HIV is associated with opportunistic infections that are potentially fatal such as pneumonia, tuberculosis, Cryptococci meningitis; cytomegalovirus; certain cancers; hepatitis among others. Treatment of opportunistic infections is associated with high health care cost and substantially reduces the victim's productivity. There exists substantial scientific evidence that early initiation and adherence to ART reduces the probability of transmission of the virus to unaffected persons (Gardner, et al., 2010). Although ART has effectively reduced HIV mortality, ART adherence remains a challenge in management of HIV in infected people and reducing HIV transmission. It’s estimated that 1 in every 20 HIV infected person in the US discontinued ART (Hughes, et al 2014). Nonadherence to the treatment reduces efficacy. Moreover, non-adherence could yield mutation if the virus causing drug-resistant strains. According to Hughes, et al (2014) causes of ART nonadherence are multifactorial including factors such as pill burden, socioeconomic status, gender difference, age cohorts, stimulant use, mental health, perceived high stigma, and time interval between infection and diagnosis. Nonadherence is also related to clinical reasons where doctors recommend discontinuation due to drug toxicity or treatment of other illness that has interactions with ART.
According to Shah, et al. (2016), substantial HIV transmission could be averted through retained care of HIV infected persons. Gardner, et al. (2010) identifies evidence-based strategies that support ART adherence resulting in health improvement. The strategies include; community geographical and demographic data analysis to identify areas with widespread population health challenges; designing of ethically relevant community health improvement plan; and designing a communication strategy with colleagues and community that appropriately responds to the barriers to ART adherence in an ethnically and culturally inclusive approach. Social construction is the most significant barrier to ART adherence since people who stand out of the convention such as the LGBT community experience marginalization. The CDC (2019) reports that HIV rates are highest among the LGBT people, therefore, addressing social construction barriers is fundamental for any health improvement and prevention plan. Queer groups such as LGBT people tend to reside in environments associated with higher vulnerabilities to HIV transmission. Such queer gender groups engage in other activities such as drug abuse that not only increases their risk of HIV transmission but as well as no adherence to ART. Shah,et al. (2016) observes that the test-and-treat approach will not be effective in HIV management mostly among suboptimal groups with differentiated behavior. Therefore, as opposed to developing a plan that independently addresses ART adherence, an effective improvement plan would address underlying challenges. For example, incorporating a sensitization program on the risk of sharing needles while injecting drugs, and the potential interaction effect between ART and other addictive drugs would be effective leverage of limiting Art discontinuation and HIV transmission prevention. By complementing ART treatment psychological, and socioeconomic services, comprehensive HIV treatment and prevention could be realized simultaneously.
c. Preventing HIV Transmission in Risk Individuals
Psychosocial health factors such as depression, history of childhood sexual assault, partner violence, gender identity increase the risk of HIV. HIV high-risk groups include socially and economically disadvantaged groups, street youth gay and bisexual men, sex workers, pregnant women among others. These groups engage in high-risk behavior that exposes them to HIV infection. The CDC (2019) statistics identify the disproportionate prevalence of HIV across different groups in the US. The CDC (2019) statistics identify African American and Hispanic communities to have a higher prevalence of HIV. The disparity is higher among Gay and bisexual men in the US and accounted for 66% of new HIV diagnosis in 2017 with the majority of the gay and bisexual men unaware of their infected condition. The group is associated with high-risk sexual behaviors such as condomless sex and drug behaviors such as syringe sharing.
The inexistence of HIV vaccine implies that prevention is rather the profound approach of managing HIV pandemic. Intervention approaches in high-risk individuals may include both medical and cognitive behavioral change interventions. Rapid testing intervention is a profound intervention in reducing HIV in high-risk individuals/groups. Rapid testing is a detour from the conventional hospital testing that has been shunned due to fear of stigma and confidentiality of results by health workers. Introducing rapid VCT in communities and health facilities using rapid-test kits improves the convenience of HIV testing. Public health campaigns targeting high-risk individuals is one of the interventions that can be used to attract them to rapid testing. The FDA approves two types of medication to prevent HIV infection: PEP (post-exposure prophylaxis) and pre-exposure prophylaxis (PrEP) Administration of daily PrEP among the uninfected high-risk individuals is an HIV prevention intervention. CDC (2019) reports that proper use of PrEP reduces the risk of HIV infection by 92%. PEP, on the other hand, is administered within 72 hours after potential HIV exposure to reduce the probability of infection. Addressing patient-provider communication appropriateness on the use of PEP and PrEP impacts on treatment effectiveness.
Cognitive behavioral change interventions focus on couples, families, peer groups, individual or institutions such as media, prisons, universities or religious centers. Intervention efforts that educate the significance of sterile syringe, syringe sharing, use of condoms and testing for STI among high risk gay and bisexual men, for example, reduces the risk of HIV infection exposure. Peer outreach strategies that address the social identity differences ensure a differentiated approach that is unique to the different groups. CDC statistics indicate that HIV incidence continues to increase among teenagers and adolescents Americans despite the stabilization of HIV rates among other groups. The statistics identify 56% of new HIV diagnoses in 2017 were among youths under 35 and were mainly sexually transmitted implying the need for community-level cognitive behavior programs that are youth sensitive. Organizing HIV training session during prenatal visits is one of the intervention approaches that nurses can integrate to ensure proper treatment and prevention of HIV transmission among pregnant women. As well partner services offered at community centers can significantly reduce transmission of HIV to the uninfected partner. Counseling services that seek to cultivate responsible for the behavior of the HIV infected reduce the probability of transmission of the virus.
Conclusion
It’s no doubt that HIV is no longer a new threat to public health as advancement in ART medicines has enabled an increase in life expectancy of HIV infected persons compared to the HIV uninfected population. A multidimensional approach is fundamental in managing HIV. The fundamental multidimensional initiatives ought to seek realizing early diagnosis, adherence in treatment and protection of infection among high-risk individuals. Addressing the fundamental challenges that result in disproportionate HIV prevalence in the US is the cornerstone of successful intervention efforts seeking to address HIV prevalence.



References
CDC. (2019). Basic Statistics | HIV Basics | HIV/AIDS | CDC. Retrieved April 17, 2019, from https://www.cdc.gov/hiv/basics/statistics.html
Cihlar, T., & Fordyce, M. (2016). Current status and prospects of HIV treatment - ScienceDirect. Retrieved April 17, 2019, from https://www.sciencedirect.com/science/article/pii/S1879625716300207
Dailey, A., Hoots, B., Hall, I., Song, R., Hayes, D., Fulton, P., … Velleroy, L. (2016). Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays — United States. Retrieved April 17, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708685/
Fauci, A., Redfield, R., Sigounas, G., Weahkee, M., & Giroir, B. (2019). Ending the HIV Epidemic: A Plan for the United States. | HIV | JAMA | JAMA Network. Retrieved April 17, 2019, from https://jamanetwork.com/journals/jama/article-abstract/2724455
Gardner, E., McLees, M., Steiner, J., del Rio, C., & Burman, W. (2010). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. - PubMed - NCBI. Retrieved April 17, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/21367734
Hughes, A., Mattson, C., Scheer, S., Beer, L., & Skarbinski, J. (2014). Discontinuation of antiretroviral therapy among adults receiving HIV care in the United States. - PubMed - NCBI. Retrieved April 17, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/24326608
Marcus, J., Chao, C., Leyden, W., XU, L., Quesenberry, C., Klein, D., … Silverberg, M. (2017). Narrowing the Gap in Life Expectancy Between HIV-Infected and HIV-Uninfected Individuals With Access to Care. Retrieved April 17, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5427712/
Shah, M., Risher, K., Berry, S., & Dowdy, D. (2016). Epidemiologic and Economic Impact of Improving HIV Testing, Linkage, and Retention in Care in the United States | Clinical Infectious Diseases | Oxford Academic. Retrieved April 18, 2019, from https://academic.oup.com/cid/article/62/2/220/2462686
Spaulding, A., Kim, M., Corpening, K., Carpenter, T., Watlington, P., & Bowden, C. (2016). Establishing an HIV Screening Program Led by Staff Nurses in a County Jail. Retrieved April 18, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4492874/
Wallace, K., Okoro, I., Carrasquillo, O., Prado, G., & Kenya, S. (2019). Strategies to Improve HIV Testing in African Americans. Retrieved April 17, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4489406/