Post by Former NIMH Director Thomas Insel: Achieving an AIDS-free Generation
When Secretary of State Hillary Clinton visited NIH last November, she spoke of an “AIDS-free generation” and the promise of research to achieve this goal. AIDS is an infectious disease, and not surprisingly, most NIH AIDS research is supported by NIAID. But the AIDS epidemic is driven by behavior, so NIMH has been an important part of the NIH fight against HIV/AIDS for over two decades. Later this month, NIMH research on HIV/AIDS will be well represented at the XIX International AIDS Conference. The mere fact that this meeting is being held here is big news. Since 1993, people living with HIV have been banned from travel to the United States. The travel ban was lifted in 2009, allowing the International AIDS Conference to be held in the United States for the first time since 1990.
It’s important to consider how AIDS research has had an extraordinary impact on morbidity and mortality over the past two decades. In 1990, a diagnosis of AIDS usually meant a lifespan of months to, at most, a few years, with this brief life marred by severe infections and disabling complications like Kaposi’s sarcoma. Today, a young adult infected with HIV can expect to live into his or her 60s or longer with a greater likelihood of dying from heart disease than AIDS. While there is still no cure, AIDS has become a chronic disease, treated effectively with antiretroviral therapy (ART).
By contrast, in this same two-decade period, we have seen little reduction in morbidity or mortality from any mental disorder. Indeed, some disorders have increased markedly in prevalence. And mortality, measured by suicide, has been relatively unchanged compared to the dramatic reduction seen with AIDS. What lessons can we take from the progress in HIV/AIDS for other disorders in the NIMH mission?
Obviously it helps to know the etiology of the disease and have powerful, effective treatments. But much of the progress in AIDS in recent years has been the development of combination prevention strategies. For example, a recent study demonstrated a staggering 96 percent reduction in HIV transmission when individuals infected with HIV initiated and adhered to ART. 1 This finding builds on earlier research that showed HIV-negative individuals can take ART to effectively reduce their chance of acquiring HIV infection. 2 In each study, ART was provided in concert with state-of-the-science behavioral counseling to promote safe sex practices, distribution of free condoms, regular HIV testing, and immediate referral upon receipt of a positive HIV diagnosis, all of which amounts to a combination prevention approach. Earlier this week the FDA approved the first medication for HIV prevention. Most important, these studies suggest that treatment is a necessary part of prevention—an insight that may be useful for mental disorders as well as this communicable disease.
But simply developing combination prevention strategies is not enough. Recent modeling data demonstrate that only 28 percent of individuals living with HIV in the U.S. have their HIV viral load suppressed—a critical benchmark for both good clinical outcomes and for preventing new infections. 3 Several steps need to be taken to realize the full benefit from combination prevention, including:
- Increasing HIV testing to identify individuals who are unaware of their HIV-positive status (the CDC reports that one in five people, or about 240,000, do not know they are infected with HIV)
- Linking those who are HIV-positive to appropriate care promptly, such as starting ART according to current treatment guidelines
- Ensuring that individuals remain engaged and retained in HIV care.
The point for mental disorders: early detection, early treatment, and patient engagement are critical. In the search for a cure for mental disorders, we have for too long sought a magic bullet. In AIDS, we know there is no single magic bullet, but new uses for current treatments may have been the missing piece to end the epidemic. But either for AIDS or mental disorders, the impact of even the most effective treatment will be limited if it is given too late or if patients don’t take it. For both chronic disorders, solving behavioral issues will be critical for saving lives.
A critical step towards an AIDS-free generation will be combination approaches that include universal HIV testing—which incorporates testing into standard medical care so everyone can know their HIV status. The mantras of “test and treat” and “treatment as prevention” are today becoming key components for HIV treatment and prevention. Those able to attend the International AIDS Conference in Washington, DC, either in person or through the daily webcasts provided by the meeting organizers will learn much more about “test and treat,” “treatment as prevention,” and many other new opportunities for HIV/AIDS research and treatment. How amazing it is to realize we are now focusing on the endgame: combining the power of biomedical and behavioral treatments along with public health policies to achieve an AIDS-free generation.
1 Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, Kumwenda J, Grinsztejn B, Pilotto JH, Godbole SV, Mehendale S, Chariyalertsak S, Santos BR, Mayer KH, Hoffman IF, Eshleman SH, Piwowar-Manning E, Wang L, Makhema J, Mills LA, de Bruyn G, Sanne I, Eron J, Gallant J, Havlir D, Swindells S, Ribaudo H, Elharrar V, Burns D, Taha TE, Nielsen-Saines K, Celentano D, Essex M, Fleming TR; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505. Epub 2011 Jul 18. PubMed PMID: 21767103; PubMed Central PMCID: PMC3200068.
2 Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, Goicochea P, Casapía M, Guanira-Carranza JV, Ramirez-Cardich ME, Montoya-Herrera O, Fernández T, Veloso VG, Buchbinder SP, Chariyalertsak S, Schechter M, Bekker LG, Mayer KH, Kallás EG, Amico KR, Mulligan K, Bushman LR, Hance RJ, Ganoza C, Defechereux P, Postle B, Wang F, McConnell JJ, Zheng JH, Lee J, Rooney JF, Jaffe HS, Martinez AI, Burns DN, Glidden DV; iPrEx Study Team. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010 Dec 30;363(27):2587-99. Epub 2010 Nov 23. PubMed PMID: 21091279; PubMed Central PMCID: PMC3079639.
3 Centers for Disease Control and Prevention (CDC). Vital signs: HIV prevention through care and treatment—United States. MMWR Morb Mortal Wkly Rep. 2011 Dec 2;60(47):1618-23. PubMed PMID: 22129997.