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Unmet Needs in the Treatment of HIV


The panel discusses unmet needs that remain in the treatment and management of HIV.

Adam C. Welch, PharmD, MBA: Let’s talk a little about the future of care in HIV and some of the unmet needs and future directions of treatment. What are some unmet needs we’re seeing with HIV treatment?

Shauna Applin, ARNP, CNM, AAHIVS: We’ve alluded to the nonoral medications. I wouldn’t call it an unmet need because it’s coming, but creativity in how we dose antiretrovirals is a big 1. We’re starting to get a taste of what that could be for our patients. The other things I thought of were community engagement, but a critical effort to do that. What does it look like on the prevention and treatment sides for communities that are at highest risk or are overrepresented in the HIV epidemic, to not just mention them but have them a part of the solution? I’m describing that as community engagement because it’s critical. We’ve talked about payers, prescribers, and patients coming together, and another part of that grouping is community leaders who are willing to have sexual health conversations and to say, “This is unique about my community.” Maybe you need to come to us. Maybe it’s the language barrier. You have an interpreter, but there’s so much stigma and shame around HIV, so having an interpreter sitting in the room isn’t helpful. Community engagement is an unmet need that’s going to focus on the social determinants of health that are driving the HIV epidemic.

Adam C. Welch, PharmD, MBA: Public health goals through the Ending the HIV Epidemic [EHE campaign] on where we see the status of HIV in 2030. How can payers and providers come together to reach some of those goals?

Alina Orozco, RN: By working collaboratively. The departments of health are key for HIV initiatives. We have 7 areas in Florida, and we’re working with them. That’s the key. It’s everybody working together and reaching out, and the needs are different. In Florida, we have urban areas and rural areas. We have individuals, especially in rural areas, get their HIV treatment from the community departments of health and community health centers. That’s key: working with those individuals, establishing those relationships, and bringing into the payer space providers who have the expertise. As we move a little further along, maybe [including] community-based organizations that have experience addressing the social determinants of health because it’s not just 1 type of approach. It’s going to have to be a collaborative approach to get to where we need to be for ending the HIV epidemic.

Ann Khalsa, MD, MSEd, FAAFP, AAHIVS: Part of the goal of the EHE program, Ending the HIV Epidemic, is to get 90% of individuals who have HIV diagnosed. We’re still not there. [Then we want to] get 90% of them on treatment sustained, and get 90% of them successfully suppressed. It’s 90-90-90. That means 73% would be virologically suppressed. Internationally, that bar has been raised to 95-95-95. We’re still trying to get to 90%, 90%, 90%. Most of our states are in the high 60s, not in the 70s. It’s location and region dependent, and getting to those outlying communities is critical. We have communities of African American gay men and transgender individuals in our Phoenix area who need more PrEP [pre-exposure phrphylaxis] and outreach, yet it’s been very difficult to get into them. Even when we have PrEP and linkage navigators, they’re very private. There’s a bit of a barrier. [We need to] figuring out how to partner with them to get to these vulnerable and at-risk individuals. We’ve got to be thinking outside the box more and working with community liaisons and partners.

Christian B. Ramers, MD, MPH, FIDSA, AAHIVS: You’ve heard several times that working together is key. These End the HIV Epidemic goals are just going to sit on the shelf unless we get to the implementation of them. The silos are not helping us. I work internationally, and there are African countries ahead of us in terms of the 90-90-90 goals. That’s why the WHO [World Health Organization] went to 95-95-95, because when you have a single-payer health system that’s well organized and has strong public health, then everyone is on the same page. Unfortunately, we don’t have that. We have a fractured health care system. With all these little barriers, it almost punishes the individuals on the margins because they’re harder to engage. How can payers help the EHE initiatives? By allowing flexibility and reimbursement for testing in nontraditional settings, by sharing data and using the data collaboratively with the public health systems that are in place. Our public health infrastructure has been underfunded for decades. COVID-19 showed us some of the flat-footedness we had because there’s been grinding away on their budgets. In the United States of America, we all have to work together to get to these goals and close that knowledge and implementation gap. We know what we have to do. We have metrics. We know what works for prevention and treatment. We all need to work together to do it.

Shauna Applin, ARNP, CNM, AAHIVS: We’re talking innovation, but payers have to pay for the medications, and we’re still facing that. Either the medicine or the recommended regimen isn’t covered, or you have to split it up to make it covered. Or the prior authorization system is put in place as a disclaimer: you can get it, but you have to jump through hoops. The hoops are time and resource intensive, and they’re a blockade to access. That’s the other piece. We’re trying to be innovative in our answers about reaching 90-90-90, but some of the barriers are as basic as access to medical care and antiretrovirals—the ones that we need, the recommended regimens.

Christian B. Ramers, MD, MPH, FIDSA, AAHIVS: It’s easy to be discouraged when we see 30,000 new infections per year. Some jurisdictions have chipped away and made progress. In San Francisco, where it’s a small county, they were having 400 to 500 new infections per year for a while. Now they’re just under 200. That curve is steeply going downward. Why is it happening that way? Because there’s such awareness. There’s a good public health campaign there. PrEP is available to almost everybody. The state of California has a program to cover PrEP for uninsured individuals. There’s high community awareness, and that’s how we’re going to get to 0 or end the epidemic, by having accessible testing and PrEP everywhere. Lots of social support to get patients with social determinants of health challenges into care and linked to care, and suppressed.

Ann Khalsa, MD, MSEd, FAAFP, AAHIVS: Part of that expanded testing is not only individuals who self-determine that they want to go get tested but all the individuals who don’t realize they need to be tested. That goes back to the providers. We’ve got to order the tests. There’s a big roadblock for a lot of providers who don’t want to think about this. One thing that Centers for Medicaid & Medicare Services has is UDS, the Uniform Data System, a metric that looks at the proportion of individuals who’ve been tested for HIV. Like cervical cancer, mammograms, and the rest, there’s a UDS measure for HIV testing. If all health care systems were mandated to put that in, and you get your funding—I hate this metric, but your funding is based on your performance—and you show that you’re increasing the percentage of individuals getting HIV tested, that’s 1 way to get it out there. For our system, getting HIV testing as an opt-out in all clinics helped drive that goal. [We said] “We have to do this.”

Adam C. Welch, PharmD, MBA: I’m hearing that prevention is the theme around this. [That means] making advances in prevention [by] incentivizing care through quality metrics, such as testing for more individuals. Focusing on that prevention is going to be key. An ounce of prevention is worth it. It’s going to be much more valuable down the line.

Ann Khalsa, MD, MSEd, FAAFP, AAHIVS: PrEP is more than 99% effective if you take your pill every day. The only reason the injection was superior in Africa is because the individuals weren’t taking the oral comparator arm. It’s adherence, but we’ve got to have PrEP out there. Individuals aren’t realizing they’re at risk, and I don’t like seeing new patients. It’s preventable.

Shauna Applin, ARNP, CNM, AAHIVS: Community conversations around PrEP are critical. If you see yourself in need of it, those are the ones who are taking PrEP vs the ones who are truly in need of HIV prevention but don’t assess that as a risk. [This requires] individualizing it in a cultural context. Looking at the Black population in Miami is a different from the Black population in Tacoma. [We need to have] regional conversations around what messaging looks like to help someone assess their own risk and to see that they have this powerful tool at their fingertips. That’s critical because the technology is there, but the messaging is behind.

Christian B. Ramers, MD, MPH, FIDSA, AAHIVS: We’ve had HIV exceptionalism for a long time, where you have to go to an HIV specialist for care. To some extent that’s true, but PrEP is the 1 thing that has to straddle that space into primary care. We need to get PrEP to be part of what family medicine, internal medicine, and OB-GYN [obstetrics-gynecology] are doing because there aren’t enough specialists. By the time patients see us, they already have HIV. But this should be much more widespread. There are 1.2 million individuals with HIV in this country. Dawn Smith at the CDC [Centers for Disease Control and Prevention] estimated that 1.2 million individuals are at risk of HIV and should be on PrEP to prevent those new infections. The last time I checked, only 15% to 20% of them are accessing that. If you’re a payer and all you care about is the financing of this, think of all those 80% of individuals who are unprotected right now. Those are going to be the next 30,000 infected, and the next 30,000 the year after that. Those are going to be the individuals on antiretroviral therapy for their lifetimes.

Transcript edited for clarity.

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