What is 100-100-100?

By: Ranier Simons, ADAP Blog Guest Contributor

The ongoing Covid-19 pandemic is a glaring reminder of the importance of the global efforts to address other epidemics and pandemics. After over 30 years of such efforts, worldwide there has been success with polio. Wild poliovirus was virtually extinct in 2020 with only about 140 cases remaining.[1] However, two serious remaining global disease crises are HIV/AIDS and Hepatitis C (HCV).

In 2020, it was estimated that there were 37.7 million people living with HIV/AIDS, and an estimated 58 million people with chronic Hepatitis C.[2][3] The strongest two-pronged approach to fight both is testing and treatment. In 2014, UNAIDS, the Joint United Nations Programme on HIV/AIDS, came up with a target known as 90-90-90. The goal was to have 90% of all persons living with HIV/AIDS aware of their status, 90% of all diagnosed on sustained antiretroviral treatment, and for 90% of those on treatment to have an undetectable viral load by 2020. 

The WHO, World Health Organization, proposed a similar target for HCV in 2016. They pledged to globally eliminate HCV by 2030. This elimination included a target of 80% those with HCV to be in treatment, a 90% reduction in new infections, and a 65% reduction in liver-associated deaths as a result of hepatitis C.[4] 

Photo Source: UNAIDS

The 90-90-90 goal was not met in 2020 and it is not likely that HCV will be eradicated by 2030. Were the goals too ambitious or was there something missing in the execution of the efforts? 

The focus has always been on testing and treatment. It is of the utmost importance to have widespread testing to identify those that need treatment in order to get them into treatment. However, what had previously been missing was discourse on barriers to testing and treatment. In 2021, the UNAIDS Global AIDS Strategy acknowledged the existence of structural barriers to HIV and HCV testing and services. 

The challenge has been that solving the problem of these hurdles has not been included in the system of testing and treatment. The structural hurdle of lack of fulfilment of basic needs should be a systemic part of treatment. Human nature prioritizes stable shelter, food, and safety over seeking out testing and adherence to treatment regimens.

This is especially true in the population of people who inject drugs (PWID). Intravenous drug users are 29% more at risk to contract HIV and 40% of new HCV infections worldwide.[5]

Photo Source: Yahoo!

In response to understanding the importance of including the effective meeting of basic needs as part of disease prevention, a new target, 100-100-100 is being discussed in global health circles. It is initially being considered through the lens of PWID regarding HIV and HCV. The goal is to have stable housing for 100% of PWID who have housing instability, offering substance abuse treatment to 100% of PWID that desire treatment, and giving 100% of PWID access to harm reduction services.

Stable housing means safe and consistent shelter. It means having a stable place to eat and prepare meals. Having stable housing provides a place for self-care and identity.  Stress is lowered when one has a safe stable place to live as well allowing focus on other needs. A sense of community results from stable housing as well. When groups of PWID have stable housing, they can create a sense of belonging and care for each other communally. 

Having a stable place to live and rest also facilitates successful substance abuse treatment. Taking away stressors of basic survival allows a person to redirect their energies towards bettering their lives. Coupled with substance abuse treatment is harm reduction. Harm reduction services come in many forms.[6] Most importantly it is acknowledging the complicated etiology of drug use. It is the realization that drug use does happen, and it is necessary to help people along the continuum of complete abstinence from drug use to the other end of safer and “responsible” drug use starting at whichever stage PWID find themselves.

Reaching this 100-100-100 goal, along with aggressive strides toward testing and treatment, is the growing discourse that is providing hope towards the eradication of HIV and HCV. Removing the inequalities of lack of basic needs will help not just PWID but the greater population at large living with HIV and HCV as well.

[1] Kaiser Family Foundation. (2021, Oct 29). The U.S. Government and global polio efforts. Retrieved from https://www.kff.org/global-health-policy/fact-sheet/the-u-s-government-and-global-polio-efforts/
[2] UNIADS. Global HIV and AIDS statistics fact sheet. Retrieved from https://www.unaids.org/en/resources/fact-sheet
[3] World Health Organization. (2021, Jul 27). Hepatitis C. Retrieved from https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
[4] World Health Organization. (‎2016)‎. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. World Health Organization. Retrieved from https://apps.who.int/iris/handle/10665/246177
[5] UNAIDS. (2017, Jan 1) 90–90–90: an ambitious treatment target to help end the AIDs epidemic. Retrieved from https://www.unaids.org/en/resources/documents/2017/90-90-90
[6] Principles of harm reduction. National Harm Reduction Coalition. Retrieved from https://harmreduction.org/about-us/principles-of-harm-reduction/ 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

HIV and Covid-19 Breakthrough Infections

By: Ranier Simons, ADAP Blog Guest Contributor

Presently, there is a world-wide surge in Covid-19 infections. This surge not only includes unvaccinated people, but partially and fully vaccinated people as well. The Omicron variant, specifically, has proven to be responsible for a sizable spike in infections here in the United States. Constantly evolving research shows that Omicron embodies some ability to evade both protections from vaccination as well as natural immunity from previous Covid-19 infection.[1] Given that there has been an increase in breakthrough Covid-19 cases regardless of vaccination type, what are the implications for people who are fully vaccinated and living with HIV?

Photo Source: McLaren

Developing data is showing that people with decreased immune function are at increased risk for Covid-19 breakthrough infection. One such study, by Sun et. al, specifically shows that people living with HIV, people on immunosuppressive drugs due to solid organ transplantation, and people with rheumatoid arthritis are at increased risk for breakthrough infection compared to those without any sort of compromised immune status.[2]

Examination of breakthrough Covid-19 infections, specifically, in the HIV-positive population is in an early stage. Thus, a large amount of data does not exist. However, there have been a few early studies that have given insight.

When discussing breakthrough Covid-19 cases it is important to define the lens of inquiry. Two major lanes of discourse are: discussions of the incidence of breakthrough cases and discussions of actual hospitalizations due to breakthrough cases. 

MedRxiv, the preprint server for health sciences, reports a longitudinal study regarding incidence of breakthrough cases. MedRxiv reports new medical research that has not yet been peer reviewed. Even though the study is not yet ready to be used in evidence-based practice, it still has great value.

The study, conducted by Coburn et. al, was done on a population of 109,599 subjects.[3] The subjects were selected from the Corona-Infectious-Virus Epidemiology Team (CIVET)-II cohort. This cohort consists of four different cohorts with subjects sourced from networked health systems and academic health centers. The purpose of the study was to compare breakthrough infections between those with HIV and those without. There were 31,840 people living with HIV and 77,759 that did not have HIV. The measured incidence of infection was taken 210 days after full vaccination.

The rate of breakthrough infection of fully vaccinated people is very small in relation to the number of people in the United States who are fully vaccinated. However, the study did conclude that the patients with HIV had a higher likelihood of breakthrough infection than those without HIV. The cumulative incidence was 2.8 percent and 2.1 percent, respectively. Additionally, the breakthrough infection risk was 41 percent higher in people living with HIV.

While this study population is not representative of the entire HIV-positive population of the country, there still is value in the result. Most importantly, the study did not find that there was a statistically significant difference in the breakthrough incidence of those with viral suppression compared with those with elevated viral loads or advanced HIV disease.

Along with incidence of breakthrough infection, it is important to explore actual hospitalizations due to breakthrough infections. Again, there currently is not a plethora of data specifically pinpointing hospitalization of HIV-positive individuals due to breakthrough infection. However, there is developing research that indicates hospitalizations as a result of breakthrough infections are more likely in people with co-morbidities.

It is complicated to research hospitalizations due to breakthrough infections because it hard to determine if a hospitalization is solely due to vaccine breakthrough or is due to another issue concurrent with the vaccine breakthrough infection. One promising analysis has shown that fully vaccinated people hospitalized with Covid-19 infections were more likely to be hospitalized because of other issues.[4]

Photo Source: Daily Maverick

Lo et. al analyzed data of 120,000 covid hospitalizations from Cosmos. Cosmos is a HIPPA-defined Limited Data Set of over 120 million patients. The data is medical record data from hundreds of hospitals and organizations that utilize EPIC electronic medical record system software.

The analysis compared Covid-19 breakthrough hospitalizations with unvaccinated Covid-19 hospitalizations. The purpose was to see if the two different groups were being treated for the same things. Common covid-related complication treatments include things like viral pneumonia diagnosis, dexamethasone treatment, respiratory failure diagnosis, and ventilator treatment.[5] The result of the analysis was that fewer people with breakthrough Covid-19 diagnosis had one or more of these complications as compared to the unvaccinated Covid-19 hospitalized patients. It was gleaned that the breakthrough Covid-19 hospitalizations were do more to primary diagnoses other than Covid-19.

The overall theme of all the ongoing scientific research is that while HIV-positive people have increased risk of breakthrough infections, vaccination is still extremely important and drastically reduces the likelihood of serious illness or death due to Covid-19. Seropositive individuals should get vaccinated as well as continue wearing effective masks and practicing all other precautions such as hand sanitation and other preventative measures. Vaccinated HIV-positive people should not be excessively fearful of breakthrough infections, just cautious and responsible in their behaviors and self care.

[1] Kupferschmidt, K., Vogel, G. How bad is Omicron? Some clues are emerging. Science, 374(6573), 1304-1305. https://doi.org/10.1126/science.acx9789
[2] Sally B Coburn, et al. (2021). COVID-19 infections post-1 vaccination by HIV status in the United States. medRxiv. doi: https://doi.org/10.1101/2021.12.02.21267182
[3] Sun, J. et. al. (2021). Association between immune dysfunction and COVID-19 breakthrough infection after SARS-CoV-2 Vaccination in the US. JAMA Intern Med. Published online December 28, 2021. doi:10.1001/jamainternmed.2021.7024
[4] Lo, J., Amin, K., Cotliar, D., Rae, M, Cox, C. (2021, Dec 15) Covid-19 breakthrough hospitalizations. Retrieved from https://www.healthsystemtracker.org/brief/characteristics-of-vaccinated-patients-hospitalized-with-covid-19-breakthrough-infections/
[5] Yek C, Warner S, Wiltz JL, et al. Risk Factors for Severe COVID-19 Outcomes Among Persons Aged ≥18 Years Who Completed a Primary COVID-19 Vaccination Series — 465 Health Care Facilities, United States, December 2020–October 2021. MMWR Morb Mortal Wkly Rep 2022;71:19–25. DOI: https://www.cdc.gov/mmwr/volumes/71/wr/mm7101a4.htm?s_cid=mm7101a4_w

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Living with HIV & Making Heads or Tails Over Covid-19 Vaccinations

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

The ongoing Covid-19 pandemic has been especially hard for people living with HIV/AIDS. Concerns over already being immunocompromised are only compounded by the social isolation from family, friends and colleagues. The economic and social impact has been profound for the HIV community.[1] For the long-term survivors among us, seeing Covid-19 wreak havoc brings back dark memories of the earliest days of the AIDS epidemic's fear, stigma and obituaries. Now forty years into one epidemic desperate for a cure (and vaccine), we've also witnessed the marvels of modern-day medicine with the advent of vaccines to protect against the novel coronavirus SARS-CoV2. Yet, too many people living with HIV/AIDS remain unvaccinated against Covid-19. While concerning for many of us, it is also important to understand the reasons behind their vaccine hesitancy. Doing so provides the best opportunity to educate and empower them.

What remains a definitive analysis on the intersection between HIV and Covid-19 is the summary published last year by the Kaiser Family Foundation, "Key Questions: HIV and Covid-19." According to the authors, "This analysis explores key questions around Covid-19 and HIV – what we know and what we are still learning."[2] Read it!

Photo Source: WAOW - ABC News 9

Among the reasons behind vaccine hesitation is fear of the unknown. Mistrust remains high in certain segments of the HIV community. Mistrust of the government. Mistrust of the pharmaceutical industry. Mistrust of the news media. And for good reason, because the HIV community has a long history of being dismissed, disparaged, and harmed by these institutions during the height of the AIDS crisis. The recent headlines blaming people living with HIV for variant development only furthers the distrust. Adding fuel to the fire is confusion over what to believe because sometimes the messaging offers conflicting conclusions. All of the science in the world, no matter how compelling is the data, might not be enough to sway the HIV community's vaccine hold-outs.

It is undeniable that Covid-19 has disproportionately impacted marginalized communities, including people living with HIV/AIDS. The University of Delaware found that among Delawareans living with HIV, "many reported a deep sense of isolation, declines in physical or mental health, increasing economic hardship and uneven access to health care." According to Tricia Wachtendorf, director of the University of Delaware-based Disaster Research Center, participants living with HIV were much more likely to use words like 'fear' or 'scared' when describing Covid-19, as opposed to 'anxious' or 'concerned" among the general population.[3]

The report findings shouldn't come as any surprise since people living with HIV more likely to get sick with, die from Covid-19. Prior to the Delta and Omicron variants, Penn State College of Medicine researchers had already sounded the alarm that people living with HIV should be prioritized to receive a Covid-19 vaccine. Their research concluded HIV increased the likelihood of Covid-19 infections by 24%, and a 78% higher risk of death.[4]

Yet, another study out of the University of California, San Francisco found that people with HIV had fewer — but more severe — SARS-CoV-2 infections than peers. That said, researchers suggested the lower infection rates could be driven by "greater caution and sheltering in place."[5]

Matthew A. Spinelli, MD, MAS, an assistant professor of medicine at the University of California, San Francisco summarized: “Although the data are mixed, people with HIV, particularly those at lower CD4 counts, are likely at a somewhat higher risk of severe Covid-19. Vaccination is an important step to protect from severe Covid-19.”[6]

The Centers for Disease Control & Prevention (CDC) has acknowledged that the effect of HIV infection on Covid-19 outcomes is unclear. The agency's own Morbidity and Mortality Weekly Report (MMWR) analyzed Covid-19 severity and Covid-19–associated deaths among hospitalized patients with HIV-infection in Zambia, which concluded: "HIV status alone was not significantly associated with severe Covid-19 at admission or during hospitalization or with Covid-19–associated death. However, among HIV-positive persons, those with severe HIV disease were more likely to develop severe Covid-19 and were at increased risk for Covid-19–associated death. Ensuring that persons maintain HIV disease control, including maintaining ART continuity and adherence, achieving viral suppression, and addressing and managing underlying medical conditions, could help reduce Covid-19–associated morbidity and mortality in sub-Saharan Africa."[7] 

Those findings were mirrored by a study by the All India Institute of Medical Sciences (AIIMS) in Delhi, which concluded people living with HIV/AIDS may be less susceptible to Covid-19. The AIIMS study indicates the seroprevalence of Covid-19 in people living with HIV/AIDS to be lower than the general population. However, researchers did caution that HIV-immunocompromised populations aren't necessarily at a lower risk for infections or hospitalizations.[8]

Photo Source: British HIV Association

"Puzzling" is a word coined by TheBody's Larry Buhl when he posed the question, "Could People Living With HIV Have Worse Outcomes From Covid-19, Even if Vaccinated?" Buhl's analysis does an excellent job at conceptualizing many of the concerns expressed by people living with HIV/AIDS who question the need for the jab.[9] "If I'm medication adherent and undetectable, then how can I be immunocompromised," is one of the statements we often hear from certain circles in the HIV community. What makes this article particularly useful is how Buhl tackles vaccine safety and efficacy.

What we have learned over the last year is that nothing is for certain, evidenced by one study suggesting the Covid-19 vaccination is as effective for people living with HIV as those without,[10] and yet another study results are showing that some people living with HIV have lower than expected antibody levels after receiving the Pfizer or Moderna Covid-19 vaccines.[11] As we continue to educate people living with HIV/AIDS about the novel coronavirus SARS-CoV2, it is important to keep individual perspective in mind. It is easy to see how some unvaccinated peers view the ongoing pandemic through the sense of six of one, half a dozen of the other.

Ongoing education centers on HIV-positive patients should have no fear of Covid-19 vaccinations. “Interaction between ARVs (antiretroviral drugs) and Covid-19 vaccines has also been non-reactive, therefore it does not cause any harm to the patients,” says Kire Stojkovski, MD, a doctor at the Farr Institute. “It is therefore recommended for everyone to get vaccinated. Those patients with advanced (matured) HIV infections should be given an extra jab to make sure that they are well safeguarded from Covid-19.”[12]

We contend that getting vaccinated against Covid-19 is the best option for the HIV community. In fact, it is why last year we launched the #YourVaccineIsWaiting public awareness campaign. But there is no doubt still too many people living with HIV/AIDS are trying to make heads or tails over getting the jab. In fact, evidence suggests that the vaccination rates among our HIV-positive peers reflects rates among the general population.[13] There is never a bad time to educate someone about the benefits of being vaccinated against this virus, which has already taken 842,141 (as of January 11th) souls from us in the United States, alone.

[1] Waterfield, K.C., Shah, G.H., Etheredge, G.D. et al. Consequences of COVID-19 crisis for persons with HIV: the impact of social determinants of health. BMC Public Health 21, 299 (2021). https://doi.org/10.1186/s12889-021-10296-9
[2] Dawson, L., Kates, J. (2021, May 20). Key Questions: HIV and COVID-19. Kaiser Family Foundation. Retrieved online at https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-hiv-and-covid-19/ 
[3] Miller, Beth (2021, May 21). Living with HIV during a global pandemic. Medical Xpress. Retrieved online at https://medicalxpress.com/news/2021-05-hiv-global-pandemic.html
[4] Cox, Tracy (2021, May 11). People living with HIV more likely to get sick with, die from COVID-19. Medical Xpress. Retrieved online at https://medicalxpress.com/news/2021-05-people-hiv-sick-die-covid-.html
[5] Dreisbach, Eamon N. (2021, May 9). People with HIV had fewer — but more severe — SARS-CoV-2 infections than peers. Healio. Retrieved online at https://www.healio.com/news/infectious-disease/20210506/people-with-hiv-had-fewer-but-more-severe-sarscov2-infections-than-peers?utm_medium=social&utm_source=twitter&utm_campaign=sociallinks 
[6] Dreisbach, Eamon N. (2021, May 9). People with HIV had fewer — but more severe — SARS-CoV-2 infections than peers. Healio. Retrieved online at https://www.healio.com/news/infectious-disease/20210506/people-with-hiv-had-fewer-but-more-severe-sarscov2-infections-than-peers?utm_medium=social&utm_source=twitter&utm_campaign=sociallinks 
[7] Chanda D, Minchella PA, Kampamba D, et al. COVID-19 Severity and COVID-19–Associated Deaths Among Hospitalized Patients with HIV Infection — Zambia, March–December 2020. MMWR Morb Mortal Wkly Rep 2021;70:807–810. DOI: http://dx.doi.org/10.15585/mmwr.mm7022a2external
[8] Pandey, Sahil (2021, June 30). People living with HIV/AIDS may be less susceptible to COVID: AIIMS study. Yahoo Finance. Retrieved online at https://ca.finance.yahoo.com/news/people-living-hiv-aids-may-113113395.html?soc_src=social-sh&soc_trk=tw&tsrc=twtr
[9] Buhl, Larry (2021, July 6). Could People Living With HIV Have Worse Outcomes From COVID-19, Even if Vaccinated? The Body. Retrieved online at https://www.thebody.com/article/people-hiv-worse-outcomes-covid-19-vaccinated/?ic=700100 
[10] Cooper, Alex (2021, August 10). Study: COVID Vax as Effective for People With HIV as Those Without. Yahoo News. Retrieved online at https://news.yahoo.com/study-covid-vax-effective-people-183612408.html?soc_src=social-sh&soc_trk=tw&tsrc=twtr
[11] Guerrero, Desirée (2021, November 3). Do COVID-19 Vaccines Work as Good for People Living with HIV? Yahoo News. Retrieved online at https://news.yahoo.com/covid-19-vaccines-good-people-161826829.html?soc_src=social-sh&soc_trk=tw&tsrc=twtr
[12] Loria, Keith (2022, January 11). HIV Patients Should Have No Fear of COVID-19 Vaccinations. Managed Healthcare Executive. Retrieved online at https://www.managedhealthcareexecutive.com/view/hiv-patients-should-have-no-fear-of-covid-19-vaccinations. 
[13] Melville, Nancy A. (2021, December 27). COVID-19 Vaccinations in People With HIV Reflect General Rates Despite Higher Mortality Risk, Study Says. Medscape. Retrieved online at https://www.medscape.com/viewarticle/965585 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

Our Patient Advocacy during the Covid-19 Pandemic's Uncertainty

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

Over the last two years patient advocacy replaced face-to-face meetings with Zoom. It substituted highly-effective legislative fly-ins on Capitol Hill (and state legislatures) with unimpressive Twitter storms. And it left many organizations scrambling to find their place in this new world of uncertainty. The ADAP Advocacy Association isn't immune from the realities surrounding the Covid-19 pandemic, especially since we represent an immunocompromised constituency.

Photo Source: Hearts in Service Blog

In March 2020, we suspended face-to-face advocacy literally as we were preparing to host the year's first HIV/AIDS Fireside Chat in Atlanta, Georgia. Our organization opted not to host Zoom meetings because the Fireside Chats have a sense of intimacy about them, but also because we quickly learned that many stakeholders were experiencing what was labeled "Zoom fatigue" at the time. That decision carried into last year, too. Aside from a series of the virtual patient support meetings held both in 2020 and 2021, we've sat (in)patiently waiting for this pandemic to subside.

Fortunately, some of our national partners stepped-up their advocacy game and hosted extremely impressive virtual conferences. Among them, HealthHIV and its SYNChronicity 2020 (SYNC 2020), and the Biotechnology Innovation Organization (BIO) and its 2020 Patient and Health Advocacy Digital Summit. The ADAP Advocacy Association opted to fund scholarships for advocates and patients living with HIV/AIDS to attend these events. 

But we're optimistic about returning to 'normal' this year!

The ADAP Advocacy Association has targeted June 2022 for the resumption of the HIV/AIDS Fireside Chats, and other patient advocacy events. That will, of course, largely depend on the ever-changing circumstances on the ground, evidenced by what is unfolding before our eyes with the Omicron variant. It is our goal to host a Fireside Chat in Atlanta over the summer, and then Chicago in the fall.

In the meantime, we will continue to focus on the intersection between HIV/AIDS and Covid-19. In 2020, we awarded Covid-19 community grants to community-based, nonprofit organizations addressing the pandemic's impact on marginalized communities living with HIV/AIDS. In 2021, we launched #YourVaccineIsWaiting public awareness campaign targeting marginalized groups living with HIV/AIDS. This year, we will invest more of our resources into monitoring how Covid-19 is impacting our community, as well as encouraging immunocompromised populations to get vaccinated...and boosted! Their lives depend on it, literally.

Finally, we're excited to welcome our new ADAP Blog Guest Contributor, Ranier Simons, MHI. Ranier prides himself on data science capabilities to drive better healthcare. He recently earned his Master of Healthcare Innovation Health Informatics from Arizona State University - Edson College of Nursing and Health Innovation.

Patient advocacy, as we knew it, came to a screeching halt in March 2020. Then in 2021, patient advocacy experienced a roller coaster ride of ups and downs. It is too early to know what 2022 will bring, but the ADAP Advocacy Association remains optimistic about the future of the patient advocacy environment, and we stand ready to respond accordingly. We look forward to you joining us in this endeavor, too!

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.