Why I Love the International AIDS Conference

~Written by Jessica Taaffe, PhD (Contact: Jessica.Taaffe@twigh.org; Twitter: @jessicataaffe)

Originally published on Global Health NOW

I remember my first International AIDS Conference well.  It was 2010, and I attended the conference in Vienna to present a poster on my PhD thesis work. Walking through the conference one day, I came upon a group of activists loudly protesting for better access to harm reduction services, like needle and syringe programs and opioid substitution therapy.

I thought, “WHAT kind of conference is this???”

I’m a biomedical scientist. I was trained that science is neutral, objective, dispassionate. So I was naturally shocked by the activism at the conference. My perspective on this has changed since then, and it’s why I now love the International AIDS Conference. At this conference, scientists ARE activists; they are part of the large and inclusive community of people working to end AIDS. And at this conference, all of those people–scientists, policy makers, activists, civil society, communities living with or affected by HIV—come together.

Science, policy and activist communities don’t often intersect. At conferences scientists usually focus on research advances and less on how to put them into policy and practice. Conversely, high-level policymakers attend meetings that set global agendas but few scientists are in the room.

At this conference, they do intersect—and interact.  Scientists have access to sessions hosted by organizations setting global HIV policy. They can give the context of their evidence and influence how it is used (or not).  Policymakers and program directors have access to the latest research advancing the field, helping inform their recommendations and program implementation.  

And those researchers and policymakers have an opportunity to directly interact with the communities affected by the HIV epidemic.  For example, I attended a pre-conference event next door to a session on transgender rights. The cheering and loud applause seeping through the walls warmed my heart.

Mutual access and dialogue between communities is critical. As a scientist, a better understanding of affected communities or populations leads to more targeted research or solutions.  For instance, research presented yesterday indicates that African women are more susceptible to HIV infection and pre-exposure prophylaxis (PrEP) isn’t as effective in some of them due to differing vaginal microbial strains.  Targeting treatments against the responsible bacteria may enhance current and future HIV prevention efforts.  

For activists, having access to the science allows them to make demands and personal decisions based on the evidence. Men who have sex with men have been enthusiastic and early adopters of PreP. When these communities interact, real change happens.  

I love the International AIDS Conference because it epitomizes the HIV movement–the coming together of an expansive and diverse community with the common goal of ending AIDS.

That is what I want to see in global health: I want scientists to see how their research directly improves the lives of people.  I want them to be informed of larger issues in the field that may shape their research or inspire new studies. I want scientists to be PASSIONATE about their science and use it to directly advocate for policy change.  I want policymakers to appreciate the complexity of the research process and use evidence appropriately.  I want them to see the impact of their decisions on the lives they affect.  

I want more communities living with a disease or at risk from the disease to be science-literate and empowered to advocate for what the health services they need.

As the 21st International AIDS Conference unfolds this week in Durban, South Africa, I hope the global health community is paying attention.  Colleagues, this is how you mobilize an equitable, science-driven, people centered, and effective health response.  We need much more of these events in global health.

Will We Witness the End of HIV in Our Lifetime?

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

December 1st of every year is designated as World AIDS Day, a day devoted to increasing knowledge and awareness about the impact of HIV/AIDS around the world. This year is no different, and over the last few months and years some exciting things have been happening regarding HIV/AIDS.

The year 2013 has become known as the “turning point” or “tipping point” in the HIV/AIDS epidemic. This describes the fact that 2.3 million people began anti-retroviral medication in 2013 while only 2.1 million new infections were diagnosed. In other words, more people are receiving treatment and fewer people are becoming infected than ever before. If we keep this accelerating HIV scale-up through 2020, UNAIDS predicts we could see the end of HIV/AIDS by 2030

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Figure 1. WHO infograph detailing the impact of expanding ART (antiretroviral therapy)

In the United States there has been a lot of media coverage, over the last year or two, surrounding pre-exposure prophylaxis (PrEP) for use by HIV-negative people to prevent HIV infection. PrEP is daily medication regimen utilizing an HIV drug called Truvada. Studies have shown that people who take PrEP as directed were 92% less likely to contract HIV. However, although it is increasing, PrEp usage remains lower than anticipated. Some barriers include a lack of PrEP awareness in people who are most at risk for HIV, some medical provider resistance to prescribing PrEP and some inconsistent insurance coverage. Additionally, PrEP continues to suffer from an image problem. When PrEP first became available, many critics were skeptical of its effectiveness in real-world settings and thought that it would undo years of work to educate folks about the dangers of HIV/AIDS. Critics also thought that being able to take a daily drug to prevent HIV would promote promiscuity and unsafe sex. A recent study in JAMA Internal Medicine proves the critics wrong on some of their fears.

An HIV/AIDS vaccine has been on the horizon ever since the epidemic was discovered. However, as we learned more about HIV, it became apparent that developing a vaccine was going to be a challenging effort. While there continue to be many HIV vaccines at various stages of development, scientists are excited about one being developed by one of the scientists who identified HIV as the cause of AIDS, Dr. Robert Gallo. His team at the University of Maryland School of Medicine’s Institute of Human Virology is beginning human trials on a potentially groundbreaking HIV vaccine. Instead of targeting different HIV viral markers to help the immune system recognize and eliminate HIV-infected cells, Dr. Gallo and his team’s vaccine targets HIV when it enters the body to prevent it from infecting cells.

All of these promising developments relating to HIV/AIDS should not overshadow the challenges that still lie ahead. Many people do not know they have HIV because they’ve never been tested. The Berkshire town of Reading in the UK is expanding its HIV testing program by offering free tests because it has more than double the UK average of HIV-positive people. The number of HIV-positive people in Russia continues to increase and has reached almost 1 million people. Some countries are passing anti-gay legislation and there is a direct link between criminalizing laws and increased rates of HIV. These are the challenges some parts of the world face in the efforts to end the HIV/AIDS epidemic.

World AIDS Day provides a way for everyone to get involved in the fight against HIV/AIDS. It’s an annual day to think about the people who’ve lost their lives to AIDS-related illnesses and to champion efforts to prevent more people from losing their lives due to HIV/AIDS related causes. This December 1st do a little research, learn about the burden of HIV/AIDS in your community, and decide how to get involved. Together we can end HIV/AIDS in our lifetime.

Examining How Women are Influenced by Inaccessibility to Clean Water

~ Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

Since 1990, 2-3 billion people have gained access to improved drinking water sources, however, much is yet to be done, as billions still do not have access to safe drinking water (Dora, et al., 2015). This has led to several negative health consequences among many communities, as one-third of deaths are linked to the intake of contaminated water in low-resourced countries (West & Hirsch, 2013). Women are often responsible for housework such as cooking, cleaning and maintaining good hygiene. They are also mainly responsible for the care of children and the sick. As all of these tasks require the use of water, women in low-resourced countries are disproportionately affected by the inaccessibility to safe water.

Risks Associated with Water Collection

In 71 percent of households in sub-Saharan Africa women are responsible for collecting water (West & Hirsch, 2013).  As a result, in places such as the mountainous areas of Eastern Africa, women use up to 27 percent of their caloric intake to get water (West & Hirsch, 2013). Sometimes, they must travel a long distance, often several times in one day. This can lead to physical strain, especially among the elderly. This strain can be exacerbated by extreme heat or with heavy pumps at well sites. Water collection can also be dangerous in remote locations where there is increased risk of rape or other forms of violence.

Impacts on Women as Caretakers, and the Terminally Ill

With a high prevalence of HIV and AIDS in these regions, there has also been an increase in care needed for the terminally ill, and once again, it is the responsibility of the woman to provide the needed care (West & Hirsch, 2013). This involves emotional support, but also other aspects such as bathing and toileting. Providing this type of assistance can become more difficult when there is little accessibility to clean water. Furthermore, caregivers also have an increased chance of developing physical pain and infections because of the risks they are exposed to. Increasing accessibility to clean water will not only improve the outcomes of HIV treatment, but it will also reduce the burden of care on women. As a result, this can improve the quality of life for both groups (Figure 1).

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Figure 1: How improved water and sanitation influences the health of those with HIV/AIDS, and caretakers (West & Hirsch, 2013).

Overall, inaccessibility to clean water increases the emotional distress on women and reduces the level of care they are able to provide to those around them. When mothers have poor health status they are unable to provide the adequate resources needed for the well being of their children, which can lead to growth stunts (Requejo, et al., 2015).

Like any other public health issue, this one is complex. Many factors must be examined to determine how improvements can be made to increase the availability of safe water, while also empowering women. For example, while women have to travel long distances in order to get clean water, this also gives them a chance to socialize with other women and spend some time away from the home. Thus, what can be done to preserve this time for social interaction, while minimizing the health risks?  In order to answer this and similar questions, governments and NGOs must critically analyze social systems, specifically gender norms, health systems and physical infrastructure in low-resourced countries.

References:

Dora, C., Haines, A., Balbus, J., Fletcher, E., Adair-Rohani, H., Alabaster, G., et al. (2015). Indicators linking health and sustainability in the post-2015 development agenda. The Lancet , 385 (9965), 380-391.

Requejo, J. H., Bryce, J., Barros, J. A., Berman, P., Bhutta, P., Bhutta, Z., et al. (2015). Countdown to 2015 and beyond: Fulfilling the health agenda for women and children. The Lancet , 385 (9966), 466-476.

West, B. S., & Hirsch, J. S. (2013). HIV and H2O: Tracing the connections between gender, water and HIV. AIDS Behaviour , 17 (5), 1675-1682.  

Program Science: Improving Public Health Interventions

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com) 

Program science is a relatively new term being used to describe the application of scientific knowledge to improve the design, implementation, and evaluation of programs. Evidence-based interventions are becoming more mainstream in public health but there is still work to do to ensure that public health concepts work the way we hope they will. That’s where program science can help.

Program science extends beyond looking at the implementation of a program, which is the logistics of developing and implementing evidence-based interventions, and focuses on the bigger picture. Program science looks at entire programs, which may include more than one intervention, for a particular population in a specific context. For example, program science may look at efforts to decrease HIV rates in youth of color in a specific borough of NYC. There are probably many interventions working on this issue, targeting different populations of youth via different methods. Program science would look at how all of these interventions work together to achieve the overarching goal of decreasing HIV rates in youth of color in that specific borough of NYC.

Program science focuses on questions like, "Who should be targeted and for how long?," "What is the best combination of interventions to achieve our goal?." " How can we sustain the program?," and "What quality improvement processes exist?" Program science helps to bring together researchers, policy makers, program planners, frontline workers, and communities for an ongoing engagement to help the program succeed.

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Source: Sevgi O. Aral, 2012. Program Science: A New Initiative; A New Approach to STD Prevention Programs. 2012 National STD Prevention Conference

Program science is popular in HIV/STI work right now because such work involves long-term complex population-level behavioral interventions. For HIV/STI work, program science can be especially useful in determining why some interventions aren’t as effective as they were in the past and why some disease incidence rates are leveling out (or increasing) instead of continuing to decrease.

The Centers for Disease Control and Prevention (CDC) focused on program science at their 2012 National STD Conference. In the US, HIV/STI program science can be used to strengthen public health initiatives in a time when public health funding is decreasing and funders want to see substantial impact. Program science can ensure that money is allocated to the most effective interventions that will have the greatest impact on the population.  HIV related program science can be useful on a global scale to ensure that we fully understand the epidemic, who is impacted, and to ensure that the “money follows the epidemic and the interventions follow the evidence”.  Because each HIV affected population of the world has different characteristics it is important to not just apply one intervention to everyone but to really understand how each population is affected and what interventions would work best for each population.  

Program science is a logical progression from a focus on developing evidence-based interventions and rolling them out to a target population, to a more comprehensive focus on how various interventions are impacting the target population. this progression into a "big picture" way of looking at things will hopefully create more effective and efficient programs that contain targeted interventions to increase health of the target population. As program science continues to gain traction in public health, I believe we will see a shift to "big picture" thinking for all sorts of public health activities currently operating without this broad focus.

Review of Unite for Site Global Health and Innovation Conference 2015

~Written by Sarah Weber (Contact: sarahkweber@gmail.com)

I attended the Unite for Site Global Health and Innovation Conference last weekend which brought together over 2,000 global health and international development professionals, social entrepreneurs and students to exchange ideas and leading practices. One of the best parts of the conference was meeting committed global health professionals with the bonus of connecting with other TWiGH team members and viewers. The conference was held at Yale and participants had the opportunity to enjoy the quaint city of New Haven as well as the snow that fell throughout Saturday. The conference was similar to many other global health conferences I’ve attended but had a unique feel due to its social innovation edge and opportunity to hear from social entrepreneurs competing for the J.M.K. Innovation Prize. The innovation prize was established by the J.M. Kaplan Fund to provide grants to emerging social sector innovations.  

The conference had some very engaging and high profile speakers. I thoroughly enjoyed listening to the key-note address by the Honorable Minister of Health of Rwanda, Agnes Binagwaho, MD. She is an energetic women who isn’t afraid to speak her mind, even on controversial topics. She spoke about how Rwanda has greatly decreased its AIDS deaths, which is the fastest decrease ever in the world. She stressed how imperative it is that women have the choice for family planning since “There is no woman crazy enough to say, I want a baby every year”. She spoke about the need to meet people where they are and to move where you are needed most (rather than nice areas with beaches or better amenities). When asked what she would do if she were the Health Minister of the United States, she said she would put parents who refused to vaccinate their children on trial! Lastly, she urged us to work together and unite since “We live in one world, not three.”

Another engaging speaker was Cal Bruns, CEO/Chief Creative Incubationist at Matchboxology who presented on “What Condom Manufacturers Could Learn from Car Designers.” He spoke about a fact that car manufacturers learned long ago, that people are more motivated to purchase a product with a benefit that they want, rather than a product to prevent something they don’t want. He proposed that the condom companies should work on creating condoms with advanced technology such as stimulating beads on the inside of the condom to increase pleasure. Then men would be motivated to use condoms for the increased sensation which would as a by-product help reduce STIs and unwanted pregnancy. It was a different look on condom promotion than I’d heard before, but totally made sense.

The Social Impact Labs, which was the catalysis feature of the conference, brought together social entrepreneurs to pitch presentations about new innovations in front of a panel of judges and the audience in competition for the innovation prize. The innovation pitches ranged from nascent ideas, grassroots projects, to initiatives already underway being backed by large public health NGOs, universities and/or private companies. We heard about innovations ranging from a sex education program in Kenya teaching farmers to spread HIV prevention messages, a movement to create greenhouses in inner-city Baltimore to bring fresh produce to areas lacking produce options, to a project that creates wells to provide safe drinking water at a low cost to prevent arsenic poisoning in Bangladesh. The winning innovation was presented by Lucy Topaloff with a company called Miraclefeet which provides high quality, low cost braces for patients with Clubfoot in India. Miraclefeet won $10,000 which will be used to help provide braces to 40+ children. 

Overall it was a motivating and encouraging weekend. It’s always great to meet other public health professionals passionate about improving health and opportunities for disadvantaged populations globally. Listening to all the enthusiastic and motivated young people during the social innovation pitches drove home the idea that: great ideas + passion + commitment = opportunities. These individuals, in collaboration with their networks and connections, are turning ideas into solutions to help the less advantaged. That is inspiring!

Global Health Insights from the 2015 Gates Annual Letter

-Written by Adenike Onagoruwa, PhD (Contact: adenike.onagoruwa@gmail.com)

For the seventh consecutive year, Bill and Melinda Gates have released an annual letter, discussing the Gates Foundation’s activities and sharing progress on the fight against poverty and disease. An organization headed by two of the world’s most powerful philanthropists, the Gates Foundation funds global health, development and advocacy efforts aimed at reducing poverty and eradicating preventable diseases that disproportionately affect the developing world population.

Through its grant-making and operational activities; the Foundation has, especially in the past decade, set the health agenda for aid organizations, research institutes and even governments around the world. It is therefore quite important to pay attention to the insights, priorities and goals outlined by these primary players in the global health and development arena. With the upcoming expiration of the Millennium Development Goals (MDGs), this year’s letter evinces the momentousness of 2015.

Released at the start of the year, the 2015 Gates Annual Letter titled “Our Big Bet for the Future” makes ambitious predictions regarding the next 15 years. The big bet is this: “The lives of people in poor countries will improve faster in the next 15 years than at any other time in history. And their lives will improve more than anyone else's.” Acknowledging the absurdity of this bet in the face of seemingly worsening world problems (they do add a caveat that a handful of the worst-off countries will continue to struggle); the two give these reasons why they think there has never been a better time to accelerate progress, resulting in longer lives and better health:

●     “There will be unprecedented opportunities to get an education, eat nutritious food, and benefit from mobile banking.”

●     “These breakthroughs will be driven by innovation in technology — ranging from new vaccines and hardier crops to much cheaper smartphones and tablets — and by innovations that help deliver those things to more people.”

The key global health breakthrough they foresee happening by 2030 is that “Child deaths will go down, and more diseases will be wiped out”. Here’s how:

Cutting the number of children who die before age 5 in half again. The percentage of under-five deaths worldwide has been cut in half (1 in 10 children in 1990 to 1 in 20 today). 1 in 40 children by 2030 can be achieved by

●     scaling proven, existing interventions for saving newborn lives such as: immediate and exclusive breastfeeding for the first six months; delivering injectable antibiotics immediately a baby appears ill; basic training for resuscitating a struggling-to-breathe newborn with a hand-pumped oxygen mask; immediately drying and warming the newborn after delivery through skin-to-skin contact; and topical application of chlorhexidine to the umbilical cord for prevention of sepsis specific mortality.

●     Comprehensive immunization - almost all countries will include vaccines for diarrhea and pneumonia, two of the biggest killers of children, in their programs.

●     Improved hygiene and sanitation to reduce disease spread - through simple hand-washing and innovative toilets specially designed for the poor.

●     Leveraging on the work that has been done to strengthen country-level health systems in many poor countries.

Reducing the number of women who die in childbirth by two thirds. The number of mothers dying will go down by:

●     Increasing the number of women that give birth in healthcare facilities instead of at home.

●     Making sure that caregivers at healthcare facilities are well-supplied and well-trained.

●     Improving access to contraceptives and to information about pregnancy spacing.

Wiping polio and three other diseases off the face of the earth. Polio, elephantiasis, river blindness, and blinding trachoma can be eradicated by 2030 through:

●     Free medicines made possible by continuing donations from pharmaceutical companies.

●     Strategic delivery of these medicines aided by advances in geographic information systems for disease surveillance.

Finding the secret to the destruction of malaria. While the two are not optimistic about the elimination of malaria by 2030, they believe that all the tools for its complete eradication will be available by then. By 2030, based on early versions of these tools currently in development, it is anticipated that:

●     There will be a vaccine that will prevent the transmittal of the malaria parasite from infected persons to the mosquitoes that bite them, thus halting the spread of the disease.

●     There will be a single-dose cure that will completely clear the parasite from infected persons.

●     There will be a diagnostic test that can provide immediate results on infection status.

Forcing HIV to a tipping point. Alongside efforts to develop a vaccine or cure for HIV, HIV will be forced to a tipping point globally when:

●     The number of people beginning anti-retroviral treatment in sub-Saharan Africa surpasses the number of newly infected people.

●     The high HIV transmission rate in sub-Saharan Africa is arrested, leading to a worldwide reduction in HIV cases.                 

Progress towards these health breakthroughs will be complemented by parallel progress in agriculture (innovations to increase yield and improve nutrition content in order to increase earnings and reduce malnutrition); education (the creation of better technology to revolutionize learning, make online education easily accessible and reduce the gender literacy gap); and banking (increased access to mobile banking that gives the poor more control over their finances, makes transactions more efficient, less time consuming and makes it easier to borrow and save).

What does this letter mean to the health and development community? Well, as one of the biggest funders, the letter provides a projection of what we can expect to see in global health programming in the years to come. For instance, there will be an emphasis on scientific and technological discoveries aimed at reducing maternal and child mortality. Organizations working to develop vaccines as well as rapid, low-cost diagnostic tests and medical devices will receive priority funding. Just as the MDGs have been used as a framework for driving actions and policies in development, the goals outlined in the 2015 Gates Letter will certainly have impacts on programs and policies in many developing countries, as well as on the funding directions of other donor agencies.

The master plan of the Gates touches on several vital issues that are central to health and development and is sensitive to the gender applications and implications of proposed activities. It galvanizes public engagement with the introduction of a “Global Citizens” program that invites and provides a platform for “global citizens” to “lend their voice, urging governments, companies, and nonprofits to make these issues a priority”. Certainly, their big bet can only be attained by building collaborations within existing structures and breaking down walls between nonprofit sectors. Monetary and R&D investments by the private sector coupled with international political support will be paramount for achieving any progress. Political will and better bureaucracy at the country level is a huge determinant of success. However, it is noted that the letter does not focus much, if at all, on the development of structures that sustain interventions such as legal, policy, financial and governmental environments. The focus is rather on straightforward solutions that can be achieved while bypassing these systems and institutions.

All-in-all, the letter provides a credible, multi-sectoral agenda and it is hoped that the Post-2015 Sustainable Development Goals will be as practical as the 2015 Gates Annual Letter in providing achievable goals for improving global health in the next 15 years.

References:

Bill and Melinda Gates. 2015 Gates Annual letter. www.gatesnotes.com/2015-annual-letter

Big Stories in Infectious Diseases for 2014

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com)

Not many people probably paid much attention to public health, much less global public health, before Ebola arrived in the US and Spain. Despite the focus on Ebola, there have been other global infectious disease developments in 2014.

Antibiotic Resistance

A major threat to humans worldwide is the emergence of antibiotic resistance. According to the Infectious Diseases Society of America, the CDC, WHO, the European Union, and President Obama, the problem of antibiotic resistance has reached crisis level. This is due to the overuse of antibiotics worldwide and major pharmaceutical suppliers who have basically abandoned antibiotic development because they don’t make enough money to justify the expense. This is a major problem because we could end up going back to death rates akin to the pre-antibiotic era, where something as simple as a minor cut could be deadly. Another fact to mention is the huge use of antibiotics in agricultural animals. Agricultural use accounts for 80% of antibiotic use in the US and that continued usage gives bacteria more exposure to the antibiotics and more opportunity to develop resistance.

Hepatitis C and HIV/AIDS

In case you didn’t hear, in only a 25 year span from the discovery of hepatitis C virus (HCV), we now have a treatment that cures 95% of the people who take the pill once a day for 8-12 weeks. I want you to let that soak in a minute…….because this is huge. HCV affects something like 250 million people around the world and now we can not just suppress the virus, but can actually clear it from someone’s body. Unfortunately, right now the cost of this treatment is $74,000 or more per person, basically putting this cure out of reach of anyone in middle or low income countries. Also in 2014, the world reached the tipping point for HIV/AIDS. That means that for the first time in the 30+ year epidemic, the number of people newly infected was less than the number of HIV positive people who got access to HIV medicines. While not every individual country has reached this milestone, and we still have a ways to go to get everyone access to life-saving medication, this tipping point shows that with continued effort the end of HIV/AIDS may be nearer than we thought.

Vaccine development

Vaccines have been around for a while and humanity has tried to create vaccines for all sorts of diseases. Work is being done to create vaccine platforms that don’t involve a needle such as embedding the “stuff” of the vaccine into a microneedle array (a small disk with several microscopic points that dissolve when embedded in the skin).  There is also an effort to create a universal influenza vaccine. A universal vaccine would target viral proteins that are conserved between the different strains of influenza and don’t mutate very often, so the vaccine could be effective no matter what strains are circulating each influenza season.

Epidemics

I just want to touch on a few of the epidemics you may not have heard much about this year. There was an epidemic of enterovirus D68 this year that caused more severe disease than we had expected as enterovirus infections generally only cause mild respiratory symptoms in kids. A mosquito-borne disease, Chikungunya, has been sweeping the Caribbean and causing fever and severe joint pain. Guinea worm, affecting people living in Africa and Asia, grows inside the body and then erupts from anywhere in the body causing severe and debilitating pain. Guinea worm is on target to be the second disease eradicated in human history (after smallpox) and is being eradicated not with the use of expensive medicines but through inexpensive but challenging to implement behavioral change. 

A Comprehensive Approach to HIV and Hepatitis C Interventions

~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

One of the primary goals of public health, epidemiology, in particular, is estimating and examining the burden of disease. The burden in a population, however, is usually not just attributable to one illness or one causative agent. Many disease states carry with them the high likelihood of co-infections or opportunistic infections. Human immunodeficiency virus (HIV) and Hepatitis C (HCV) share at least one common route of transmission and often co-infect individuals. There are an estimated 40 million people worldwide who are infected with HIV and about 60-180 million globally are infected with HCV.1 Understanding the disease process as a whole means taking into consideration not only biological aspects of co-infection, but how this co-infection is propagated, or even mitigated, by patients’ behavior as well as their access to care. An all-inclusive and early detection approach to HIV-HCV treatment can help reduce the burden of disease in the affected population, and can help decrease transmission.

Effective interventions should focus on prevention, or at least early detection and treatment. This is not only good for the patient, but also for the health system. Between 2010 and 2019 it was estimated that HCV expenditures would be $10.7 billion.2 As disease progresses, costs increase (more medications, hospitalizations, etc.). Treatment should not only concentrate on drug therapy, but also address risk behaviors. Interventions, such as needle and syringe exchange programs (NSP) and opiate replacement therapy (ORT) are just some options that public health officials can use (and have used effectively) to curb HCV and HIV transmission in the community. Counseling is not a tool that should be overlooked as many of the co-infected population are affected with mental illness, a known risk factor for HIV acquisition. 

Both diseases separately represent a serious health concern, especially among injection drug using populations, but HIV-HCV co-infection introduces additional complications in treatment and disease progression of both conditions. Early interventions, especially during the acute phases of both diseases, can lead to better patient outcomes. Early treatment in co-infected individuals who have not yet been on antiretroviral therapy (ART) do better than those on existing ART regimens. The latter should be considered for treatment regimen changes to ensure minimal side effects and maximum adherence. Alcohol use in both HIV and HCV populations is a contributing factor to liver-related morbidity.3 Inclusion of alcohol and drug rehabilitation programs with drug therapy could decrease liver-related morbidity among co-infected patients. This is incredibly important because liver disease is the leading cause of mortality among co-infected individuals. 

Comprehensive interventions are useless if they cannot reach the population. Much has to be done to ensure that the delivery of these interventions captures as wide of an audience as possible. This includes having a well-trained staff of health workers and specialists who are able to support and motivate patients, convenient locations and times that are easily accessible for patients, and pricing should be affordable, if free is not an option.3 Many of the individuals taking advantage of such programs are often low-income, marginalized, and stigmatized by society. Giving these individuals the ability to take control of their condition and be aware of the risk behaviors and prevention strategies available for them could allow for better adherence to treatment, and consequently, better medical outcomes. Much like any other infectious disease that disproportionately affects low-income and vulnerable populations, the distribution and availability of resources are of utmost importance.

All of the above would be futile if there are no set standards to test and screen individuals who are most in need of these treatments. The lack of consensus among public health officials and the government regarding standardized screening among high-risk populations may contribute to the ongoing transmission of HIV and HCV, as well as co-infection. Ensuring sustainability of screening and treatment programs requires engagement and cooperation at all levels, from the patient to the care provider, to the community, to researchers, and even outward to national and international governing bodies.

1. Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol. 2006;44, Supplement 1(0): S6-S9.

2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Public Health. 2000;90(10): 1562-

3. Viral Hepatitis: Hepatitis C Treatment. US Department of Veterans Affairs.  http://www.hepatitis.va.gov/provider/reviews/HCV-treatments.asp. Page updated December 9, 2013. Accessed October 21, 2014.