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Atlanta Principles Call for Stepped Up HIV Prevention, Focus on Vulnerable Groups

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ACT UP, the Treatment Action Group (TAG), and local advocates this week launched the Atlanta Principles, calling on the Centers for Disease Control and Prevention (CDC) to increase HIV prevention efforts -- including antiretroviral treatment-as-prevention and pre- and post-exposure prophylaxis -- to lower HIV incidence rates that have remained stable overall for several years and actually risen for heavily affected groups such as young black gay men and transgender women.

At a June 10 press conference, following a meeting between prevention advocates and CDC officials at the agency's Atlanta headquarters, activists unveiled the new set of demands, accusing CDC director Tom Frieden of being "missing in action" as new infections rise among key groups despite improved prevention tools.

Widespread behavior change -- including condom use by gay men and needle exchange programs for people who use drugs -- dramatically reduced HIV incidence from its peak in the late 1980s. But the old strategies appear to have reached their limit, as indicated by the stubborn figure of 50,000 new infections per year in the U.S. over the past decade. What the overall number does not show is that while incidence continues to decline in some groups, including women, it is on the rise in others. Recent data show a 22% increase in HIV incidence among young men who have sex with men. One of the hotspots is the southeast, in the CDC's backyard.

"There are more means of preventing HIV than there have ever been. And yet in a single year the young black gay men of Atlanta become infected with HIV at a rate of 12%," said Jim Eigo of ACT UP/New York, citing a recent study by Emory University researchers. "This is a rate higher than any we find in any wealthy nation. Atlanta is the home of the CDC. Someone has been fiddling while Atlanta burns."

Fortunately, there are some highly effective new tools in the prevention toolbox. The risk of infection drops by more than 90% when the HIV positive partner in a serodiscordant couple promptly starts combination antiretroviral therapy -- dubbed treatment-as-prevention (TasP) -- perhaps approaching zero if they maintain an undetectable viral load. Truvada pre-exposure prophylaxis (PrEP) may offer nearly complete protection if used daily, while antiretroviral post-exposure prophylaxis (PEP) can stop HIV from establishing itself in the body if taken within 72 hours after exposure.

"Without real leadership and promotion from U.S. public health officials, these prevention methods will remain underutilized," the coalition of advocates said in a press release. "Without a concerted effort to address the HIV prevention needs of marginalized communities affected by high levels of homelessness, job insecurity, and HIV-related stigma, it will not be feasible or safe for individuals to access the resources they need to protect themselves."

"It is time, past time, that we as a society have honest discussions about harm reduction, substance use, sex, HIV/viral hepatitis/STI education and prevention," said Atlanta Harm Reduction Coalition executive director Mona Bennett. "We must have national leadership on these discussions and follow-up actions."

The Atlanta Principles follow in the tradition of the Denver Principles, which heralded the self-empowerment of people living with AIDS in 1983, as well as ACT UP's Treatment Agenda delivered at the 1989 International AIDS Conference in Montreal. The new manifesto offers a set of steps the CDC can take now to radically change and improve the way it currently conducts HIV prevention in the U.S., including:

  • HIV prevention messaging and education materials that deal frankly with sex and bodies;
  • Work with local health departments to use the Affordable Care Act to plug leaks in the HIV treatment cascade;
  • Better promotion and availability of treatment-as-prevention, PrEP, and PEP;
  • A national TasP information campaign for the general public to de-stigmatize HIV by dispelling misinformation about its transmission;
  • PEP and PrEP information tailored to groups historically at risk for HIV;
  • CDC seminars, webinars, workshops, and conferences that train medical providers about PEP and PrEP guidelines -- and how to pay for it;
  • Prevention funding, targeted to populations at highest risk, to promote TasP, PEP, and PrEP, while continuing to fund older prevention efforts that make sense, such as condom distribution.
  • Revised HIV testing guidelines for key populations, expanded testing beyond traditional points of care, and encouragement of next-generation tests that better detect acute HIV infection -- when viral load is highest;
  • More sensitive HIV epidemiology that allows for precise data about key subgroups such as transgender women (now usually classified with gay men), trans men, sex workers, homeless people, the new wave of young heroin injectors, and specific sexual networks of gay and bisexual men;
  • Reforming of the National HIV Behavioral Surveillance (NHBS) system;
  • Comprehensive sex and sexual health education for young people in schools, including LGBT/queer people;
  • Focused surveillance of subpopulations living with HIV, including seniors and women, so that the information gathered can help improve care;
  • Real partnership between the CDC and communities most affected by HIV.

In the wake of the 1987 Helms Amendment, which prohibited federal funds for materials that promote homosexual activity, CDC content guidelines prevented the agency from producing material that deals openly with sex or drug use, or funding such materials produced by local health departments. "In silencing itself and its partners, CDC has abandoned its mandate to keep the nation healthy," according to the principles. "CDC has an ethical responsibility to promote the health of its constituents and their rights as individuals, even when this proves inconvenient, controversial, unpopular or difficult."

"Teachers and administration staff must be accountable for creating safer spaces to talk about sex, harm reduction, and HIV/AIDS on a regular basis," Alan Guttirez, a case manager at Lyric, a San Francisco organization serving LGBT youth, told HIVandHepatitis.com. "Parents and school staff must accept that middle and high school students have varied sexual desires for people of all genders -- and we must meet every student's need in talking about the kind of sex they may enjoy."

On the PrEP front, community-based activists, service organizations, and local health departments have had to set up local PrEP education efforts without much guidance, funding, or technical assistance from the CDC, the activists charge. And although it has been the standard of care for healthcare and emergency workers and others for many years, "PEP is hardly better known than PrEP among community members and practitioners." ACT UP/New York has successfully targeted the city's health department to make PEP more widely available.

"To HIV activists and service providers from affected communities, CDC has often seemed eerily absent from this freshly challenging, rapidly changing prevention landscape," according to the document. "Community members have been subjected to a huge amount of HIV-related research over the past thirty years. Now that this research has shown just how crucial TasP, PEP, and PrEP could be for lowering the number of new infections, this knowledge must be translated quickly into policies and programs that could help relieve our communities of the massive burden of disease into the foreseeable future."

"It's time to hit the reset button on our HIV prevention efforts and the CDC must also make rapid change to confront an epidemic that is out of control in certain populations," David Evans of Project Inform told HIVandHepatitis.com. "Most of what is being sought through the principles is common sense. We must track the epidemic more carefully and we must use and promote the new tools that we have, such as TASP and PrEP, to reverse upward trends."

6/11/14

Sources

ACT UP and TAG. ACT UP to Tom Frieden: You’re MIA on HIV New Infections on the Rise in Key Subpopulations, Despite Options for Prevention. Press release. June 9, 2014.

ACT UP. The Atlanta Principles. June 2014.

J Eigo. The Neverending Epidemic: And How We Can End It. Huffington Post. June 9, 2014.