In some ways the US can be thought of as advanced in terms of HIV. Research into vaccinations and trials of new medications, as well as the roll-out of PrEP, put the country ahead of many others when it comes to establishing pioneering biomedical approaches to HIV prevention. But, in other ways they have set a precedent that other countries would do best not to follow. One of these, it could be argued, is the approach to HIV treatment. This can be seen most clearly when looking at what is called the treatment cascade.
The treatment cascade shows the drop off in people living with HIV compared with people receiving care, on medication and accessing treatment. Looking at the graph below the difference in these figures for the UK and US are striking. Whilst both have almost the same numbers of individuals living with HIV and are aware of their status (77% and 79% respectively), numbers for those in treatment are very different. In the UK, the majority of people living with HIV are: in care (73%), on treatment (64%) and have an undetectable viral load (58%). In the US, less than half of people living with HIV are in care (44%) and only a shockingly small proportion are on treatment (24%) and have an undetectable viral load (19% – 3 times less than in the UK).
A significantly lower proportion of people living with HIV are accessing the care that they need or on anti-retroviral medication in the US compared with the UK. The results of this on physical and mental health, as well as transmission, cannot be overstated and can be seen in the higher rates of HIV across the pond. HIV prevalence in the US is about 3 times that of the UK. Thos is just about the highest of any ‘developed’ country (0.6% in US vs. 0.2% in UK). But why is this? Well, they key reason is that HIV medication in the States is not free, except for the very poorest, and to access anti-retrovirals you must have health insurance. While in the US generally only about 15% of people don’t have medical insurance, less than 20% of people living with HVI have private medical insurance (see here) . Delaying treatment has health consequences for the individual and increases the onward risk of transmission, which in turn have financial implications which make the treatment of HIV much more expensive and costly for society as a whole. For these reasons, the US approach to HIV treatment could be described as unacceptable, and many would argue shameful, particularly for such a rich country.
Whilst the UK has a much higher proportion of people with HIV in services and on treatment (arguably world leading, in fact) this doesn’t mean that we should rest on our laurels. Rather, those working (see paper by Professor Jane Anderson see here ) in HIV argue that we need to focus on better understanding the reasons why there is a treatment cascade in the UK and work to overcome barriers to accessing treatment and care. This involves asking why the UK figures are not closer to 100%. Stigmatisation when using and accessing services, barriers to service access, societal discrimination, problems affecting treatment adherence and knowledge and understanding of HIV transmission and treatment are all issues that require more research with concrete changes at service delivery if further progress is to be made. Thus, while the UK’s approach to HIV treatment is admirable, in many ways, there is still work to be done to ensure HIV rates are reduced and treatment is more effective.