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Preventing and Treating HIV

Although not identified as such at the time, the first official report on an unusual set of infections in five young, previously healthy, gay men was published by the U.S. Centers for Disease Control and Prevention (CDC) in the June 5, 1981 edition of its “Morbidity and Mortality Weekly Report” (MMWR). The story was picked up by the mainstream media and, by year’s end, 270 cases of severe immune deficiency had been reported among gay men nationwide – 121 of whom had died.

On Sept. 24, 1982, the CDC named the disease AIDS (acquired immune deficiency syndrome) and released its first case definition: “a disease at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known case for diminished resistance to that disease.”

It was not until 1983, however, that scientists identified HIV (human immunodeficiency virus) as the cause of AIDS – which actually is the terminal Stage 3 phase of HIV – although HIV did not become the official name for the virus until May 1986.

Further research indicated treatment of HIV, when diagnosed early in Stage 1 (acute HIV infection), could both slow or prevent progression to Stage 2 and significantly reduce the chance of transmitting the virus to someone else.

In 1985, the military began testing all new recruits for HIV, rejecting those who tested positive; that is still the policy. Nevertheless, by 2009, the government estimated the HIV infection rate among active-duty personnel to be 0.15 to 0.20 per 1,000.

Stage 2 is marked by HIV inactivity – the virus is still active but reproduces at extremely low levels. Without medication, Stage 2 can last 10 years or more; with treatment, Stage 2 can last several decades, during which the patient can still infect someone else, although the rate of transmission is low.

Stage 3 is full-blown AIDS. Without treatment, life expectancy in Stage 3 is typically three years, with death coming from a growing number of severe “opportunistic” diseases that the patient’s heavily compromised immune system is unable to fight. This is also the stage in which the patient is most infectious.

As the virus’s nature, progression, and Stages 1 and 2 treatments became known, the U.S. military and Department of Veterans Affairs (VA) modified their responses. Once labeled a “gay disease” transmitted during sex – which is the highest risk – infection also can occur through exposure to infected blood via used needles, transfusions, open wounds, etc.

In 1985, the military began testing all new recruits for HIV, rejecting those who tested positive; that is still the policy. Nevertheless, by 2009, the government estimated the HIV infection rate among active-duty personnel to be 0.15 to 0.20 per 1,000.

While being HIV positive will block someone from joining the military, it is not cause for discharge if diagnosed after an individual is in uniform.

HIV test blood draw

Air National Guard Lt. Col. Kendall Sawyers, clinic nurse for the 118th Medical Group, draws a blood sample from an airman on Sept. 17, 2016, in Nashville, Tennessee. The blood samples will be sent to Air Force laboratories and tested for HIV. Testing for the virus is a key component in preventing spread of the disease. U.S. Air National Guard photo by Airman 1st Class Anthony G. Agosti

“It currently blocks some OCONUS [overseas] assignments, varying by service. You cannot deploy into a combat zone and there is some variation among the services about where you can serve OCONUS. But those policies currently are being reviewed,” according to chief of Epidemiology and Threat Assessment at the U.S. Military HIV Research Program (MHRP) Dr. Paul T. Scott, M.P.H.

During the first two decades of the fight against AIDS, many at-risk individuals avoided testing, which increased the disease’s spread.

“There is still some stigma to being HIV positive,” Scott acknowledged. “We’re just beginning to formally look at that with the repeal of ‘don’t ask, don’t tell,’ which freed us of most restrictions of asking service members about the perceived and actual stigma and how that influences their care. We then use that to reduce barriers of any kind to access to treatment.”

VA follows CDC testing recommendations – every veteran should receive at least one HIV test in his or her lifetime, more frequently if in a high-risk-factor group. The CDC also recommends universal testing for any group with an undiagnosed prevalence above 0.1 percent. While that is a low prevalence, the impact on public health is significant. Since they began testing, about 47 percent of all veterans accessing VA health care services have been tested.

“Veterans in VA care have a high prevalence of HIV, so we recommend everyone get tested,” said Maggie Chartier, Psy.D., M.P.H., deputy director of the HIV, Hepatitis, and Related Conditions Program in the VA Office of Specialty Care Services. “At the end of 2016, we had 28,354 patients with HIV who had had at least one HIV visit in the previous calendar year. That was down slightly from 2015 and 2014. There had been an increase in 2012 – and an even bigger increase in 2013 – but, basically, the numbers have remained relatively stable.

“Veterans in VA care have a high prevalence of HIV, so we recommend everyone get tested,” said Maggie Chartier, Psy.D., M.P.H., deputy director of the HIV, Hepatitis, and Related Conditions Program in the VA Office of Specialty Care Services.

“Our 2009 state-of-care report showed 23,463 in 2008. The biggest difference was in 2009, when the law changed to remove the legal document for signed consent before we could test, which led to a huge increase in testing and thus more cases diagnosed.”

As with the overall U.S. population, the highest risk group in the military and among veterans is African-American males.

“There are significant differences by race and gender and age,” she added, “keeping in mind we only provide care for about 30 percent of all veterans. The HIV patients are mostly male – 97 percent – with African-Americans making up about half, whites 42 percent, 8 percent Hispanic/Latino, and less than 1 percent other groups.

“We also have an aging cohort, which has caused some shift. The majority [of HIV-positive veterans] are over 45, older than those in the general population. For 2016, about 14 percent were between 40 and 49, only 10 percent younger than 40, 34 percent between 50 and 59 and 34 percent 60 to 69; the mean age is about 56.”

Of all the developments in diagnosis and treatment of HIV/AIDS, the most significant biomedical advancement in recent years has been PrEP – pre-exposure prophylaxis – according to Scott.

“Behavioral risk reduction, condoms, test-and-treat, all a huge part of prevention, but HIV PrEP reduces individual risk by 90 percent or more by taking one pill a day – two anti-viral drugs – that, when taken properly, is very effective at preventing HIV infection. But PrEP is not just a pill, it’s a whole program, including risk-reduction counseling at each visit and intensive follow-up every three months,” he said.

Shaffer AIDS fight

Rick Shaffer, Ph.D., director of the DOD HIV/AIDS Prevention Program (DHAPP) at the Naval Health Research Center in San Diego, California, leads a discussion about the work the U.S. military has done in fighting the global HIV/AIDS pandemic during a World AIDS Day event on Dec. 1, 2016. DHAPP develops and implements culturally focused, military-specific HIV prevention, care, and treatment programs in more than 80 countries and is the executive agent of the President’s Emergency Plan for AIDS Relief. U.S. Navy photo by Regena Kowitz

“A lot of people are looking at different ways to take the meds – currently, it’s every day, combined with the PrEP follow-up. You screen for STDs [sexually transmitted diseases] as well as HIV, so you’re really bringing them into an overall STD prevention program through PrEP.”

According to the CDC, PrEP can stop HIV from taking hold and spreading throughout the body.

“It is highly effective for preventing HIV if used as prescribed, but it is much less effective when not taken consistently. Daily PrEP reduces the risk of getting HIV from sex by more than 90 percent. Among people who inject drugs, it reduces the risk by more than 70 percent,” the agency said.

“There are guidelines from the CDC on how to manage a PrEP program, but there are some military-unique nuances. One of those is that service members move around a lot, so you have high turnover and high geographic variability,” Scott said. “We convened a working group [in May 2017] to look at all the issues to develop defense health issues procedures to meet the national HIV strategy goals, but also figure out how best to deliver it so service members have access wherever they are or go.

“We’re just starting to explore how to transition service members from active duty to civilian life and how that affects PrEP. We’re very closely aligned with NIH [National Institutes of Health], the DOD [Department of Defense] HIV/AIDS Prevention Program [DHAPP], and the VA. In addition, we have a very large treatment program in Africa, such as the Joint West Africa Research Group, coordinated through AFRICOM [Africa Command], that covers all infectious diseases. We also work with CENTCOM [Central Command] on a project we’re initiating in Jordan and in coordinating the blood supply for anyone treated in a U.S. or coalition facility that sometimes has to use host-nation blood supply.”

Africa has been especially hard-hit by HIV/AIDS, which has significantly affected economic and political stability across the continent, degraded military medical readiness, and weakened the national security of individual countries. As a result, HIV/AIDS programs are a key component of AFRICOM’s security cooperation and humanitarian assistance activities.

Mandated by Congress in 1986, MHRP has become a world leader in HIV vaccine research, threat assessment and epidemiology, HIV diagnostics, and cure research. MHRP is centered at the Walter Reed Army Institute of Research (WRAIR), U.S. Army Medical Research and Materiel Command.

DHAPP, designated the executive agent for DOD HIV support for foreign militaries in 2001, is the DOD implementing agency for the President’s Emergency Plan for AIDS Relief (PEPFAR), established in 2003.

Based at the Naval Health Research Center (NHRC) in San Diego, California, the program works to develop and implement culturally focused, military-specific HIV prevention, care, and treatment programs in more than 80 countries.

Aside from Northern Command (NORTHCOM), which is responsible for the defense of North America, the geographic combatant commands (COCOMs) work closely with the U.S. military’s various HIV programs.

European Command (EUCOM) works with PEPFAR and DHAPP to develop sustainable programs designed to eliminate HIV/AIDS as a threat to regional stability through partnerships and interagency collaboration. Command efforts include counseling and testing to obtain HIV/AIDS status, planning appropriate intervention techniques for military members, and collecting data to establish baseline prevalence rates in the militaries.

AFRICOM, the newest of the COCOMs, is responsible for U.S. military relations with 53 African countries, focusing on war prevention rather than warfighting by working with African nations and organizations to build regional security and crisis-response capacity. Africa has been especially hard-hit by HIV/AIDS, which has significantly affected economic and political stability across the continent, degraded military medical readiness, and weakened the national security of individual countries. As a result, HIV/AIDS programs are a key component of AFRICOM’s security cooperation and humanitarian assistance activities.

HIV H9 T-cell

A colorized image of an HIV-infected H9 T-cell. National Institutes of Health (NIH) image

Pacific Command (PACOM) has been working to prevent the spread of HIV among military personnel in several Asian countries, including East Timor, India, Indonesia, Madagascar, Papua New Guinea, Thailand, and Vietnam. The Center for Excellence in Disaster Management and Humanitarian Assistance has been the primary PACOM organization implementing PEPFAR HIV efforts for militaries in the region, such as their partnership with the Royal Thai Army, which has led to the development of the HIV/AIDS Regional Training Center in Bangkok. The center provides education and training in HIV prevention, laboratory capacity building, and policy to military officers in the region.

CENTCOM is tasked with deterring and defeating terrorism, strengthening regional stability, assuring regional access, and helping build partner-nation security self-reliance in the Middle East and Southwest Asia. That has included distributing medical supplies and HIV/AIDS educational and training materials to health clinics in the region.

Southern Command (SOUTHCOM) has a primary mission to ensure the security of the United States, enhance western hemispheric security, increase regional stability through U.S. partner-nation relationships and improve the disaster response capabilities of partners in Central and South America. That includes efforts in HIV/AIDS prevention and treatment, such as the deployment of U.S. Navy hospital ships to train doctors and nurses in the latest approaches to AIDS/HIV.

The National HIV/AIDS Strategy is a five-year plan, first released in July 2010, then renewed in July 2015, detailing principles, priorities, and actions guiding the collective U.S. national response to the HIV epidemic. According to the Department of Health & Human Services, “the updated Strategy reflects the work accomplished and the new scientific developments since 2010 and charts a course for collective action across the federal government and all sectors of society to move us close to the strategy’s vision,” which, in part, is to significantly reduce the number of HIV infections.

On the home front, VA efforts to treat HIV-positive veterans recently turned to the growing technology of telemedicine for those in rural or remote areas without easy access to VA health care facilities.

As the HIV/AIDS epidemic approaches the end of its fourth decade, those responsible for the care of its military victims are cautiously optimistic about the future.

“We’re looking at using telemed in rural areas to provide care, both regionally and nationally. We’re trying to make access to care easier for those who have to make long drives to reach clinics. A lot of VA caregivers in rural areas don’t have a lot of experience with HIV, so telemed also allows HIV patients to receive specialty care. And in rural areas and small towns, many patients don’t want to be treated locally due to privacy considerations,” noted Jack Stapleton, M.D., director of Infectious Diseases, VA Office of Specialty Care Services.

“A lot of telemedicine is done at a local CBOC [community-based outreach clinic], where we have remote ways of doing physical exams with amplified stethoscopes, for example, to do a reasonable exam without putting your hands on the patient. TelePrEP also is rapidly expanding. We’re looking at whether using TelePrEP, using SkypeTM, from a patient’s home is as effective as doing it in a clinic, although they still have to go to a facility for blood tests and such. Another aspect being looked at is whether people stay in the program as well as with other methods.”

Chartier said telemedicine is one of several programs the VA is looking at to increase its health care services to HIV-positive veterans, as well as those with other medical needs.

“Each facility has community-based outpatient clinics and telemed is part of how a lot of folks in rural communities are seen. CBOCs don’t have a lot of specialty care capability, but a patient coming into the clinic can go into a room with a video system and talk with HIV specialists elsewhere. That’s part of ECHO – Extensive Community Health Outreach.

AIDS prevention abroad

U.S. Navy Reserve Cmdr. Michael Cackovic, a perinatologist from Naval Operation Support Command, gives a class on how to treat HIV during pregnancy and during childbirth at the Hospital Regional San Isidro, Tocoa, Honduras, Sept. 23, 2014. U.S. Marine Corps photo by Lance Cpl. Chloe Nelson, 2D MAR DIV Combat Camera

“If you have a physician with HIV expertise, that person would train a provider at another facility, who then would provide HIV care to local patients. We also have a home-based care program for those who find it difficult to come into a VA facility and that may be used with HIV patients in some remote areas.”

As the HIV/AIDS epidemic approaches the end of its fourth decade, those responsible for the care of its military victims are cautiously optimistic about the future.

“HIV has a proviral DNA form that integrates into the human chromosome and very long-lived memory T-cells. These cells can carry a functional copy of the virus and, if activated, can restart the virus all over again. But if you can somehow target those cells, in theory, you could cure it.”

“Many aspects are being studied. The two most exciting are cure research, looking at the latent infection of HIV. Until the last year or two, there were not a lot of studies that gave strong promise, but there are more recent ones that are, some involving gene studies and different ways of targeting latent cells,” Stapleton said. “Another important aspect is the use of longer-acting medications you only take once every three or four months. For people who have trouble taking meds regularly, this could be a huge advance.

“We used to do a lot of clinical trials, but we don’t need to as much. We have about 800 HIV-positive patients here – between the VA and the University [of Iowa] – and 90 percent of our patients have a non-detectable viral load, where the virus cannot be detected in the blood. Nationally, we are toward the top of that. And that’s pretty remarkable, due to very effective drugs. Clearly, there is a need for ongoing development of new drugs for persistent viruses, but it’s only a small percent of patients who need that.”

As to a cure … “I tend to be a sceptic. A year ago I would have said I didn’t expect to see it in my lifetime, but there is recent data using gene-editing techniques that are really exciting and have raised my optimism. I do believe it will take a novel, breakthrough approach to find a cure in the next 20 to 30 years – so maybe in my lifetime,” Stapleton replied.

“HIV has a proviral DNA form that integrates into the human chromosome and very long-lived memory T-cells. These cells can carry a functional copy of the virus and, if activated, can restart the virus all over again. But if you can somehow target those cells, in theory, you could cure it.”

 

MAJOR POINTS ON THE HIV/AIDS TIME LINE

By the end of 1985, every part of the world had reported at least one case of HIV.

In 1987, the United Nations General Assembly approved a resolution to mobilize all UN assets to fight HIV worldwide, placing the World Health Organization (WHO) in charge of the effort. The following year, the number of women with HIV/AIDS in sub-Saharan Africa exceeded men for the first time.

In July 1990, Congress passed the Americans with Disabilities Act (ADA), which, among other things, prohibited discrimination against people diagnosed with HIV/AIDS. In 1992, health officials identified AIDS as the No. 1 cause of death for U.S. men aged 25 to 44. In 1994, AIDS became the No. 1 cause of death for all Americans between 25 and 44. It held that position until 1996.

By 1999, WHO announced HIV/AIDS was the fourth leading cause of death worldwide, No. 1 in Africa, and estimated there were 33 million HIV-positive people in the world and a total of 14 million had died from AIDS and related illnesses in just two decades.

In January 2003, President George W. Bush announced creation of the President’s Emergency Plan For AIDS Relief (PEPFAR), a $15 billion, five-year plan to combat AIDS, with an emphasis on poor nations with a large number of infections. That program remains in place.

In August 2009, VA sought to increase HIV testing among veterans by dropping the requirement for written consent. In October, the FDA approved the 100th antiretroviral drug to treat HIV.

In 2013, UNAIDS announced new HIV infections had decreased by more than half in 25 low- to middle-income nations and the number of people receiving antiretroviral treatment worldwide had increased by 63 percent in the previous two years. However, the agency also reported 1.6 million AIDS-related deaths during 2012 and 2.3 million new infections, bringing the global total of HIV-positive individuals to 35.3 million – more than 1.2 million of those Americans.

Source: www.hiv.gov

 

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J.R. Wilson has been a full-time freelance writer, focusing primarily on aerospace, defense and high...


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