This paper presents a population health improvement plan for the treatment and prevention of HIV/AIDS in the United States. Beginning with an epidemiological overview of the global and domestic burden of HIV, the paper examines transmission mechanisms, existing stigma, and current antiretroviral therapy (ART) options. The improvement plan focuses on three core strategies: early HIV diagnosis facilitated by community health workers and rapid testing technologies, ART treatment adherence addressing multifactorial barriers including social, behavioral, and clinical factors, and targeted prevention interventions for high-risk individuals such as gay and bisexual men, adolescents, and pregnant women. The paper underscores the importance of a multidimensional, culturally inclusive approach to reducing HIV disparities across race, gender, and geography in the US.
The Human immunodeficiency virus (HIV) pandemic remains a prevalent public health crisis both globally and in the United States. World statistics estimated 37 million people living with HIV 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). The CDC estimates 1.1 million people were living with HIV in the US by end of 2016, with 14% of the population unaware they were living with HIV. The Centers for Disease Control and Prevention (CDC) further estimates that over 700,000 people have succumbed to HIV/AIDS since the recognition of the virus in 1981.
US HIV statistics vary across gender, gender identity, race, and region. While the pandemic is highly prevalent among young people aged 25–34, HIV statistics are proportionately higher in bisexual and gay men, who account for 66% of all HIV diagnoses in 2017. 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 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 fewest cases (CDC, 2019). While the US National HIV/AIDS Strategy 2020 seeks to reduce the burden of HIV and AIDS, the chronic nature of these diseases remains a constraint to public health.
HIV is a virus that progressively destroys infection-fighting CD4 cells, subsequently weakening the body's 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, mother-to-child infection through pregnancy, birth or breastfeeding, blood transfusion, and organ transplant. Transmission occurs only if a mucous membrane or damaged tissue is in contact with contaminated fluids, or if the fluids are injected directly into the bloodstream.
There exist myths and misinformation about other possible transmission mechanisms, such as handshakes, hugs, kisses, sharing of dishes, doorknobs and toilet seats with people living with the virus, pets, and insects. Such misconceptions manifest into existing social stigmatization of HIV and marginalization of HIV patients. 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 to HIV management. Advances in HIV treatment have considerably narrowed the life expectancy gap between people living with HIV who access 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 for preventing HIV infection. Currently, there are no commercially available curative treatments or vaccines for HIV; therefore, antiviral treatment is administered to suppress viral loads.
Antiviral treatments are administered for managing HIV-associated morbidity and preventing further transmission. Introduced in the late 20th century, antiretroviral therapy (ART) — a combination of medicines — is the primary treatment option for prolonging viral suppression and restoring the immune system. While ART does not cure HIV, it prevents the multiplication of the virus, reducing the viral load to undetectable levels, which reduces the risk of transmission. The Department of Health and Human Services (DHHS) outlines that ART should be introduced when the CD4 count falls below 350/µL. However, DHHS recommends immediate introduction of ART for pregnant patients or those with hepatitis B virus (HBV) or HIV-associated nephropathy, irrespective of CD4 count. ART is administered as a combination of three HIV medicines derived from two different drug classes, chosen from 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 primary caregivers and therefore play a frontline role in HIV treatment improvement and prevention. The role of nurses extends beyond bedside care to integrating innovative behavioral approaches that increase rapid HIV testing and ART adherence. Spaulding et al. (2016) identify higher rates of HIV screening initiated by nurses compared to physicians, demonstrating the nurse's fundamental role in HIV management. Nurses provide both critical medical and psychological care necessary for diminishing existing HIV stigmatization.
Shah et al. (2016) propose three initiatives fundamental to improving 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 performed through tests such as the ELISA test, saliva test, viral load test, and Western Blot test. Delayed diagnosis of HIV complicates prevention of transmission and management of the virus, posing a substantial healthcare implication. Dailey et al. (2017) estimate that 40% of new HIV transmissions in the US occur from people unaware of their HIV status. The study further identifies a median interval of three years between infection and diagnosis. Early diagnosis enables the HIV-infected person to enter ART care, enabling a reduction in viral load and prevention of transmission. Shah et al. (2016) estimate 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. Dailey et al.'s (2017) analysis of the dynamics of HIV diagnosis in the US identifies higher prevalence of testing among females relative to males, and among Black patients relative to other racial groups, among other categories. These findings demonstrate gaps in HIV testing in the US and the need for differentiated initiatives in promoting diagnosis among different social groups.
Over the years, Community Health Workers (CHWs) have become increasingly integrated into the healthcare setting, primarily in the management of chronic conditions. CHWs are a fundamental group in promoting the uptake of HIV testing, as they are respected lay members of the community. CHWs engage with local communities in diverse settings including local churches and markets, which provide avenues for awareness initiatives. CHWs also address a fundamental healthcare challenge — limited health care resources — thereby reducing the economic burden of managing HIV.
HIV testing approaches have predominantly followed the voluntary counseling and testing (VCT) model, mainly undertaken at healthcare centers. However, innovative approaches are emerging that increase testing uptake. Advances in testing kits have made HIV testing more convenient. The approval of rapid testing kits such as OraQuick (a 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 CHWs in promoting the use of HBHRT kits is one community-level approach to increasing HIV testing uptake. Wallace et al. (2019) propose CHW-facilitated rapid testing in culturally distinctive African American neighborhoods, arguing that CHWs could effectively address HIV misconceptions and improve HIV screening behaviors.
"Barriers to adherence and evidence-based retention strategies"
"Behavioral and biomedical interventions for vulnerable groups"
HIV is no longer a new threat to public health, as advances in ART medicines have enabled an increase in the life expectancy of HIV-infected persons compared to the HIV-uninfected population. A multidimensional approach is fundamental to managing HIV. The core multidimensional initiatives should seek to achieve early diagnosis, adherence to treatment, and protection from 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 aimed at reducing the overall burden of HIV/AIDS.
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