The Formula for Getting to Zero? Testing, Treating... and Talking

Illinois recently became the 16th state to legally recognize the marriages of same-sex couples. Much has changed for LGBT equality in the short 10 years since Massachusetts became the first state to marry same-sex couples. But vestiges of the ugly past remain in the stark disparities that exist for gay and bisexual men and transgender women in their vulnerability to HIV/AIDS.

Gay and bisexual men, particularly young men of color, are disproportionately impacted by HIV. Although men who have sex with men make up just four percent of the male population in the United States, they accounted for 66 percent of all new HIV infections in 2010. That same year, the greatest number of new HIV infections among men who have sex with men occurred in young gay and bisexual black men aged 13-24.

Transgender women, who are all but invisible in the official recordkeeping for the epidemic, are tragically vulnerable to HIV. The Lancet published a study earlier this year estimating that transgender women are 49 times more vulnerable to HIV infection than the general population. And some studies estimate that more than half of transgender women of color are HIV positive.

Even so, as I travel the country conducting educational training and outreach on behalf of The Fenway Institute's National LGBT Health Education Center, I see much reason to hope that the theme of this year's World AIDS Day, "Getting to Zero: Zero New Infections. Zero Discrimination. Zero AIDS-Related Deaths" is more than just feel-good rhetoric. I am more convinced today than ever before that we know exactly how to radically reduce the rate of HIV transmission.

I was recently in Jackson, Mississippi at a LGBT Sexual Health Summit. The state ranks seventh in the country in rates of HIV with just over 20 cases reported per 100,000 people and Jackson ranks fourth among major US cities. The state's laws are not hospitable, to say the least, toward LGBT people. Marriages of same-sex couples are prohibited by the state constitution; same-sex couples are not allowed to adopt children; and there are no legal protections whatsoever for transgender people. As my colleagues at The Fenway Institute have shown previously, equality under the law correlates with improved health. Active discrimination is not helpful, to say the least, in the quest for better health outcomes.

Still, doctors from Mississippi's primary care association, officials from the state's department of public health, and administrators from the University of Mississippi Medical School enthusiastically turned out for our training in LGBT health, which includes significant information about HIV as it relates to gay and bisexual men and transgender women. And we celebrated this year's opening of the Open Arms Health Center in Jackson dedicated to serving the LGBT community.

I had similar experiences this year in Utah, Arkansas, and Puerto Rico.

While Massachusetts, where the National LGBT Health Education Center is based, remains a national leader among states for its aggressive approach to treatment and prevention throughout the entirety of the epidemic, it is clear to me that health care providers from all quarters of our country are hungry for information on what they can do to provide better care to their LGBT patients. And that includes treatment for HIV.

In order to make progress on the lofty goals outlined in the theme of this year's Worlds AIDS Day, providers should be routinely screening everyone age 16-65 for HIV. Individuals who are at high risk for HIV based on their sexual practices and/or their use of intravenous drugs should be tested for HIV every three to six months. In addition to staying up to date about their patient's HIV status, these more frequent screenings offer invaluable opportunities for prevention intervention through the all-too-infrequent act of simply talking about HIV. This is something that clinicians need to do more of. As Atul Gawande pointed out in his New Yorker piece on spreading innovation, it is not technology, but "human interaction that is the key force in overcoming resistance and speeding change." Last, for people living with HIV, connection -- and retention--with health care is absolutely necessary. Regular blood work and a review of HIV medications every four to six months is critical to ensuring that HIV positive people have the best chance of staying healthy.

The installation of simple systems such as reminders in the Electronic Health Record; the use of rapid testing; and basic training on HIV screening, linkage to care, treatment and prevention, are relatively easy to implement. By making HIV screening a standard practice, providers will ultimately help those with HIV keep the virus at bay. This not only helps the patient in question, but also helps their family and their future sexual partners. This will be an important first step to get us to the where we all want to be: a place and time in which new HIV infections are rare.