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Commentary On Des Jarlais Et Al. (2017): Robust Public Health Policies As A Way Forward In The HIV Epidemic.

N. Whitehead
Published 2017 · Medicine

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Des Jarlais and colleagues [1] identify important trends in the decrease of HIV prevalence among non-injection drug users (NIDU) in New York City. Key lessons from this work focus upon the influence of simultaneous public health policies that address multiple factors which appear to be associated with changes in HIV prevalence (e.g. the drug epidemic, the provision of health care to those in need and the prevention of HIV infections). Adaptable local prevention strategies (i.e. fundamental common components that can be tailored to the needs of various locales to address the epidemiology of HIV transmission) have been identified as an effective approach to decreasing HIV prevalence [2], and the data presented by Des Jarlais and colleagues [1] make this case convincingly. Similarly, Okeke and colleagues reported that, in San Francisco, gaps in care for African American men who have sex with men (MSM), including diagnosis, linkage to care and antiretroviral therapy (ART) use, decreased substantially between 2004 and 2014 [3] and coincided with a decrease in HIV prevalence observed within their sample. Moreover, HIV prevalence in African American MSM was higher compared with other MSM in 2004–08 but not in 2011. Decreases in prevalence trends among such subgroups illustrate the importance of high-impact prevention strategies to control the infectiousness of a population [3–5]. While community viral load, an aggregate measure of the viral load of a population or subpopulation in a geographic area, is controversial [6,7], Des Jarlais and colleagues identify important trends in increased ART utilization. These trends support the idea that decreasing infectiousness at the community level is associated with a decrease in HIV prevalence. In the non-injecting drug user (NIDU) population treated at Mt Sinai, New York, this decrease was from 16% in 2005 to 8% in 2014 and, while the ART utilization outcome was not statistically significant (P = 0.09), it is noteworthy that it increased from 58% in 2005 to 92% in 2014. These trends add to a growing body of literature that supports high-impact population-level interventions to address the HIV epidemic [4,8]. The dramatic increase in ART utilization suggests that the New York City area implemented and sustained proactive public health policies that prioritized access to treatment and delivered that treatment successfully. A focus on ART utilization can deliver particular benefits if policies prioritize access to treatment, successful delivery of that treatment and greater engagement of patients in their care. These recommendations point to the importance of universal treatment. Ganich and colleagues support this by demonstrating that universal ART utilization could reduce HIV incidence and mortality to less than one case per 1000 in 10 years [9]. Robust public health policies that could be prioritized include targeting of high-impact populations, provision of community-focused testing and diagnosis, immediate/same-day ART and drug detoxification. Behavioral and biomedical research has not produced a unified strategy to control the HIV epidemic to date; currently, numerous strategies must be combined to create success. Further, the effectiveness of prevention strategies is a challenge to measure, as the moment at which an infection has been averted is difficult to detect. Des Jarlais and colleagues present data that make a strong case for averted infections. To dismiss these findings as natural attrition from the population over time, as discussed by the authors in their limitations section, would be a mistake. The idea that NIDU merely aged out does not provide strong support to explain these findings, as an increasing average age would not be expected if older adults were aging out and newer younger adults were replacing them. In addition, the 1.2 per 1000 person-years seroconversion rate, a substantially lower than expected incidence rate, supports changes in population-level processes in this subgroup. Similarly, there are supportive findings that ARTutilization increased while unsafe sex practices and sex with multiple partners decreased. These changes suggest that prevention messages are reaching the intended audience. Future research should focus upon integrating available data and adapting policies to the needs of high-impact communities. Des Jarlais and colleagues’ findings support not only how changes in drug use impact infection rates, but also how community viral load may be associated with reductions in HIV prevalence. The decline in HIV prevalence among NIDU entering treatment in the New York City area between 2005 and 2014 highlights populationlevel processes that signify the success of public health policies.
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