Ob.gyns. can help end the HIV epidemic

In fact, there is growing evidence that early treatment is key for both the infected individual and for individuals at risk. In the HIV Prevention Trials Network 052 study of discordant couples, for instance, early antiretroviral therapy in an infected partner not only reduced the number of clinical events; it almost completely blocked sexual transmission of the virus to an HIV-negative partner (N. Engl. J. Med. 2011;365:493-505).

The 052 study was a landmark “treatment as prevention” study. Other research has similarly shown that when the viral load of HIV-infected individuals is significantly reduced, their infectivity is reduced. And on a larger scale, research has shown that when we do this on a population basis, achieving widespread and continual treatment success, we can significantly impact the epidemic. This has been the case with the population of intravenous drug users in Vancouver, where the community viral load was significantly reduced by successful treatment that prevented new infections in this once-high-risk population.

Emerging data suggests that early diagnosis and treatment will likely also impact the likelihood of infected individuals achieving “functional cure.” The issue of functional cure – of achieving viral loads that are so low that drug therapy is no longer needed – has been receiving increasing attention in recent years, with the most promising findings reported thus far involving early treatment.

Tools for preexposure prophylaxis

For many years, we fit HIV care neatly into either the treatment or prevention category. More recently, we have come to appreciate that treatment is prevention, that a comprehensive prevention strategy must include treatment of infected individuals.

On the purely prevention side, it is important to continue educating women about safe sex behaviors. Most new HIV infections in women (84%) result from heterosexual contact, according to the CDC. For those who remain at risk of acquiring HIV despite education and counseling (eg., individuals who continue to engage in high-risk behaviors, or who have an HIV-positive partner), pre-exposure prophylaxis (PrEP) is now a safe and effective tool for preventing transmission. Patients deemed to be at high risk of acquiring HIV need to be made aware of this option.

PrEP originally was recommended only for gay or bisexual men, but in May 2014, the CDC recommended it for all individuals at risk and released the first comprehensive clinical practice guidelines for the prevention tool (www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf).

The PrEP medication, Truvada, is a combination of two drugs (tenovovir and emtricitabine) that, when taken daily on a consistent basis, significantly reduces the risk of getting HIV infection. Several large national and international studies have documented risk reductions of 73% to 92% when the medication was taken every day or almost every day. It is clearly within the purview of any ob.gyn to prescribe, monitor, and manage such prevention therapy.

The availability and relative ease of such a tool, along with advances in treatment and knowledge gained from the HIV Care Continuum, should re-energize ob.gyns. to up the ante in efforts to end the epidemic.

Experience in our clinical program that provides care and treatment to patients in the Baltimore-Washington area has taught us that we do much better when we integrate HIV care within primary care. It’s much more likely that patients will “stay close” with their ob.gyn than to another specialist.

Certainly, HIV infection has its “hot spots” and areas of much lower prevalence, but regardless of where we reside, we must continue to appreciate that the epidemic has had a significant impact on women and that this will persist unless we can all better utilize our available tools, such as early diagnosis and effective treatment that are linked long-term with other primary care physicians.

For women, ob.gyns represent a great resource for our nation to make progress toward President Obama’s National HIV Strategy.

Dr. Redfield reported that he has no disclosures relevant to this Master Class.