Of the 1.1 million Americans with HIV, nearly 20% don't know their status,and many of those who have tested positive didn't find out until years after they were infected. In 2010, 32% of people who tested positive in the U.S. received an AIDS diagnosis within one year. In honor of National HIV Testing Day on June 27, the Centers for Disease Control and Prevention issued new guidelines recommending the widespread use of the latest HIV testing technology that can detect HIV just weeks after infection, during the period known as acute infection when people are most likely to transmit the virus. Senior staff writer Lucile Scott talked to Greg Millett, amfAR's new vice president and director of public policy and former senior policy advisorat the White House Office of National AIDS Policy, about ways to improve rates of testing and drive down new infections in the U.S.
Greg Millett, amfAR vice president and director of public policy
LS: The CDC now recommends that HIV testing be a routine part of medical care, but approximately half of American adults have still never been tested. What are the continuing barriers to more generalized testing?
Greg Millett: One of the major barriers is physicians themselves. Many haven't heard about the CDC's guidelines recommending testing for all adults between the ages of 16 and 65. Previously, the testing guidelines centered around testing individuals who were at high risk for HIV. The problem is that, just like everyone else, physicians are often unable to determine with a high degree of accuracy who is at high risk for HIV and who is not. The best way to try and chip away at the high rates of undiagnosed HIV infections is for physicians to follow CDC guidelines and test as many people as possible across demographic groups and categories.
Another barrier to testing is fear. We're 30 years into the epidemic, and stigma and discrimination are still prevalent enough that people are afraid to find out whether or not they're HIV positive. We still see negative comments in the media about people living with HIV. For example, the media recently highlighted derogatory comments by the owner of the L.A. Clippers' basketball team who pointed to Magic Johnson's HIV status as a symbol of irresponsible behavior and dismissed Magic as a suitable role model for others.
LS: The number of new annual HIV infections in the U.S. has held steady at approximately 50,000 for over a decade. What role could increased testing play in driving down that number?
Millett: HIV testing in and of itself is an intervention that decreases HIV transmission risk. When people test positive for HIV, they are less likely to engage in unprotected sex with individuals they know are HIV negative. In addition, nearly 50% of new infections that take place each year are transmitted by people who are unaware that they are HIV positive and unwittingly transmitting the virus to their partners. So increasing rates of HIV testing and diagnosing those individuals who do not yet know that they are HIV positive would drive down the number of new infections that take place each year.
Additionally, over the past couple of years, scientists have conclusively proven that HIV treatment is HIV prevention. One new study showed that HIV-positive individuals who were on antiretroviral therapy and virally suppressed were 96% less likely to transmit HIV to their uninfected partners. HIV medication can also be taken by uninfected people to deter HIV transmission. Pre-exposure prophylaxis (PrEP)--which involves giving HIV medication to individuals who are HIV negative--helps prevent HIV infection even if an HIV-negative individual is exposed to the virus. So we have these powerful tools in our arsenal now that can be delivered to people who know they are HIV positive to keep them from transmitting the virus and to people who know they are HIV negative to keep them from getting the virus.
LS: What impact has the wider availability of rapid HIV tests had on testing?
Millett: Previously, people were forced to wait two weeks to find out whether or not they were HIV positive. It was a painstaking wait, and many people were just too frightened to come back to get their results. Now, within 20 minutes of either getting a finger prick or taking a saliva test, people know with near certainty whether or not they're currently infected with HIV. That's huge. You are less likely to lose that person to follow-up, and if that person is HIV positive, you're able to immediately link them into care. And now we're finding that home testing might be another tool to diagnose more people and get them into care and to ultimately reduce the number of new infections that take place each year.
"There really is the potential for the Affordable Care Act to decrease the number of HIV infections that take place each year."
LS: What impact do you think the Affordable Care Act (ACA) has had on rates of testing and who gets tested?
Millett: There really is the potential for the ACA to decrease the number of HIV infections that take place each year. You have many individuals coming into the healthcare system for the first time, and it's a way to deliver testing and treatment as prevention interventions at a larger scale. We know that people who are low-income are far more likely to be HIV positive than those who have higher incomes, and now many of those lower-income people, who previously couldn't get health insurance, can enroll under ACA.
We also know that racial or ethnic disparities in health insurance coverage and chronic illness are huge and vexing issues that have been around since the beginning of the epidemic. With the ACA, more traditionally disenfranchised populations, such as African Americans and Latinos, have access to health insurance, which in turn has the potential to impact these disparities and the domestic HIV epidemic in a very positive fashion.
LS: What should be done to encourage people in these and other populations that are disproportionately impacted by HIV to get tested?
Millett: Rates of undiagnosed infection are particularly high among African Americans, Latinos, and gay and bisexual men, particularly young gay and bisexual men. And the issue isn't that these communities are not testing for HIV--they are getting tested, but they need to get tested more frequently than other populations at less risk for HIV. Why is that? Well, the prevalence of HIV is so high within each of these communities that the likelihood of being exposed to HIV is greater than in the general population even if members of these communities are engaging in very few risky activities. Also, the fact that many racial and ethnic minorities do not have access to routine medical care heightens the possibility that people with HIV are unaware of it or aware of their HIV status but unable to afford proper medications that render them uninfectious.
Either way, more needs to be done to increase awareness, provide access to care, and increase the frequency of HIV testing. There have been large scale campaigns recently to perform expanded HIV testing and engage large numbers of people to get tested--especially if they live in specific localities with high rates of HIV. There was a big campaign called "Bronx Knows" that got more people tested in the Bronx and linked to care. A similar campaign took place in Washington, D.C., targeting blacks and Latinos, and found that expanded HIV testing efforts resulted in catching many people earlier in their HIV infection and a drastic reduction in AIDS diagnoses.
We know that community-based organizations are perhaps the best places to reach those communities that are disenfranchised or stigmatized--precisely those communities that have higher rates of HIV infection--because there's a readily established trust and cultural fluency. CDC data show that high risk groups are more likely to be diagnosed with HIV through community-based organizations that cater to those populations as opposed to private health clinics or the health department.
LS: Before joining amfAR, you were Senior Policy Advisor at the White House Office of National AIDS Policy. What is ONAP doing to encourage more people to get tested? What else could or should be done?
Millett: I was brought on at the White House Office of National AIDS Policy to help write the President's National HIV/AIDS Strategy. One of the big goals of the National HIV/AIDS Strategy is to reduce the number of new infections each year, and HIV testing figures prominently as an intervention to get to that goal. We wanted to make sure that there is targeted testing taking place in those communities that we know are at high risk, while at the same time implementing the CDC guidelines to test as many people as possible in other communities.
We worked with the CDC to expand the number of community health centers that are doing HIV testing and then linking people who test positive to care, and that is taking place. We also worked with the CDC and other entities to try and fund more sites to do expanded HIV testing, just like the work that was done in Washington, D.C., and the Bronx to try and see if those results could be replicated in other places. And we coordinated all the efforts around HIV testing across federal agencies to ensure that work on the ground was focused on delivering appropriate care to communities, rather than on responding to bureaucratic requests and paperwork.
For more information about events taking place and testing locations and resources near you, visit the National HIV Testing Day website, www.hivtest.org, or www.gytnow.org.