Scientific advances for HIV/AIDS have exploded in recent years, and doctors have new ways both to treat people who already have the disease and to prevent others from acquiring it.
But despite new research that allows scientists to track, treat and prevent HIV better than ever before, the disease continues to spread, including in Louisiana.
Baton Rouge is ranked first in the nation for estimated HIV and AIDS case rates per 100,000 people, while New Orleans is ranked third for HIV and fourth for AIDS, according to newly released 2014 Centers for Disease Control and Prevention figures.
How to link people infected with the disease to health care and why they continue to go untreated are questions that physicians nationwide — and in Louisiana — are trying to answer.
A recent New England Journal of Medicine article titled “Applying Public Health Principles to the HIV Epidemic — How Are We Doing?” offered a somewhat pessimistic view of the status quo. In the essay, Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention, and his co-authors called for doctors, as well as local and state health agencies, to adopt a more aggressive approach to combating the spread of the disease, pointing to alarming trends.
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“Most people living with HIV infection in the United States are not receiving antiretroviral treatment; notification of partners of infected people remains the exception rather than the norm; and several high-risk behaviors have become more common,” they wrote.
DeAnn Gruber, the HIV program director for Louisiana’s Department of Health and Hospitals, said she read the article as highlighting that the nation is at a crossroads in terms of HIV care.
“We’re at a real turning point in the epidemic of HIV,” Gruber said. “What they’re raising too is that even though there have been some advances, there’s still a lot of work to be done.”
At-risk communities
The work is particularly needed within smaller, often stigmatized communities.
In line with national trends, gay men contract half of all of the new HIV infections in Baton Rouge, said Timothy Young, the head of the HIV/AIDS Alliance in the Baton Rouge area.
Last year, around 24 percent of the more than 5,000 people living with HIV/AIDS in Baton Rouge were not receiving care related to the disease, according to DHH and CDC estimates.
As for preventing the spread of HIV, Young said that just telling people to have safe sex is not enough.
“There is a disconnect between that knowledge and behavior. We know that trying to teach increased and effective condom use has not been effective,” Young said.
Gruber said smaller subsets of gay and bisexual men, particularly black gay men, have higher risks of being exposed to the disease. Young said the reason involves more than race and sexual orientation, and even geography can come into play.
“People tend to have sex within their own race and ethnic groups within a relatively small geographic area,” Young said.
HIV tends to spread in some communities because of risky behaviors, such as anal sex without condoms. But other risky behaviors are on the rise as well.
Increases in opiate use nationwide have led to more HIV infections from needle-sharing, according to the CDC essay.
Baton Rouge has certainly felt the strain of opiate-usage increases, as the city recorded a record number of heroin deaths this year.
Health experts know that needle sharing and unprotected sex are problems, and they know which communities they most affect. But transforming that knowledge into action is difficult, they say.
Young, DHH and many public health experts are strong advocates of “pre-exposure prophylaxis,” a daily pill called Truvada that people with risky lifestyles can take to prevent getting HIV.
A CDC report from November said the daily pill could reduce the risk of HIV acquired from sex by 90 percent and of HIV from drug injections by 70 percent. But the CDC also estimated that one in three primary care doctors and nurses do not know about the treatment, meaning it is not as widespread as it could be.
Possible solutions
Young said the key to combating HIV is identifying every member of the community who is infected with the disease, linking them to treatment and spreading messages about prevention.
The CDC essay heralded an effort in San Francisco, where a combination of increased testing, partner notification and treatment led to a 40 percent decrease in new HIV infections between 2006 and 2014.
Gruber said New Orleans recently received two grants, totaling $5 million over the next few years, that could help build a San Francisco-like model in that city. She said the money will be directed toward building networks that address behavioral health, housing, employment and transportation for people with HIV.
Gruber said it’s likely that DHH will pluck the most successful aspects of what they do in New Orleans and implement them in Baton Rouge.
One of the state’s most successful initiatives, called “LA Links,” focuses on identifying people who are HIV-positive and connecting them to medical care and support services. The program exists in Baton Rouge, New Orleans and Shreveport, and is set to expand.
Within its two-year existence, Gruber said, around 500 people have enrolled in “LA Links.” About 87 percent of them have started receiving medical treatment.
The New England Journal of Medicine article also emphasizes the importance of newly diagnosed people reporting their partners so that they can get tested. The doctors who authored the study argue that reporting partners is a critical way to trace and stop the spread of the disease.
“Despite the importance of these services, interviews to elicit names and contact information of partners were documented to have been conducted with only about half the people who received a diagnosis of HIV infection in 2014, and patients who named partners named relatively few,” they wrote.
Louisiana state law does not require people to report their sexual partners, but Gruber said the state’s partner services office works hard to have people disclose their partners and then to inform those people of their potential exposure to HIV.
Young said asking people to name partners does not always yield results, for some people will not be honest, some do not remember and others simply do not know. He said the rise of hookup apps, like Grindr — a social networking app that lets users share their location — has led to many fleeting relationships that could make it more difficult for people to report their sexual partners.
“That’s not necessarily a positive sign when we’re trying to control the high rate of STDS that we have here in Louisiana,” Young said.
Barriers to treatment
Stigma is still the biggest barrier to getting people into testing and treatment, Young said.
He said the fear of being associated with HIV is so pronounced that more than 25 percent of those who are newly diagnosed with the disease in Louisiana have already progressed to AIDS.
“We have people who don’t want to test, don’t want to be seen accessing care or going to known providers of HIV care, and are living with the situations that may have allowed them to become HIV-positive in the first place,” Young said.
The good news for people who worry about the stigma of having HIV is that treatment is better than ever, Young and Gruber said.
HIV is no longer a death sentence with a ticking clock; people with the disease who are in treatment can live normal life spans and healthy lives.
It’s unclear how much of a game changer Medicaid expansion might be for treating people with HIV/AIDS in Louisiana. While Gov. Bobby Jindal has declined to expand Medicaid, the federal health insurance program for the poor, Gov.-elect John Bel Edwards has said he wants that to be among his first moves once he takes office.
J.T. Lane, DHH’s assistant secretary for public health, said the state already covers HIV testing and that clinics that are federally qualified health centers can reimburse patients.
DHH spokeswoman Ashley Lewis said that if Medicaid is expanded, it would open up more avenues for recipients to receive overall medical coverage and it could increase specific types of federal funding for people in the state with HIV/AIDS.
Young said the state needs to do more, although he acknowledged that HIV treatments are largely covered for patients right now because of specific federal funding in that area.
“We also know that Louisiana doesn’t have any skin in the game in the sense that there are currently no state dollars dedicated to HIV prevention, which is very sad when we have some of the highest rates,” Young said.
