Go Where the Virus Is: An HIV Micro-epidemic Control Approach to Stop HIV Transmission

Michael M. Cassell; Rose Wilcher; Reshmie A. Ramautarsing; Nittaya Phanuphak; Timothy D. Mastro

doi:10.9745/GHSP-D-19-00418

Key Messages

Essentially all HIV transmission is from people living with HIV (PLHIV) who do not know their infection status or have not yet achieved viral suppression, making support for these individuals and their risk contacts a priority for treatment and prevention efforts.
Proven approaches exist to reduce viral burden and interrupt HIV transmission from PLHIV who are not yet virally suppressed, but these approaches must be implemented with enhanced focus and scale to maximize benefit.
Improved diagnostic approaches offer new opportunities to increase public health impact by prioritizing support for unserved or underserved individuals with the greatest viral burdens and among members of their risk networks.
Policy makers should pursue the implementation and evaluation of diagnostic approaches that can focus services among individuals and networks with the greatest viral burdens.
Program managers should treat viral burden as a primary consideration in the provision of differentiated HIV services, applying an HIV micro-epidemic control framework to prioritize and tailor services for PLHIV and their risk contacts along a continuum of progression to viral suppression.

INTRODUCTION

Globally, a growing majority (59%) of an estimated 38 million people living with HIV (PLHIV) know their HIV status and have achieved HIV viral suppression by adhering to antiretroviral therapy (ART).¹ Individuals who achieve sustained viral suppression and undetectable levels of circulating virus through good adherence to ART live long, healthy lives and will not transmit HIV through sexual contact.²^–⁴ The evidence that people who have achieved undetectable viral loads will not transmit HIV sexually—that “undetectable equals untransmittable” (U=U)—underscores the prevention benefits of treatment and the rationale for the global call to achieve near-universal access to ART and viral suppression among PLHIV.⁴^–⁶

Conversely, HIV viral burden (viremia), generally measured by plasma viral load (HIV RNA copies/mL) assays, is the primary predictor of …

View Full Text