Promising new drug for treatment-resistant depression – esketamine

Treatment-resistant depression affects 1 in 3 of the estimated 16.2 million adults in the U.S. who have suffered at least one major depressive episode. For them, two or more therapies have failed and the risk of suicide is much greater. It’s a grim prognosis.

Promising new drug for treatment-resistant depression – esketamine
The chemical structure of esketamine.
Promising new drug for treatment-resistant depression – esketamine
The chemical structure of ketamine.

As there are few therapies for depression that resists treatment, the Food and Drug Administration has been considering a new treatment called esketamine. On Feb. 12, 2019, I participated in the FDA review of this drug. Practically speaking, esketamine is essentially the same as ketamine, which is a pain killer with hallucinogenic effects and used illegally. As a member of the Drug Safety and Risk Management Advisory Committee of the FDA, I voted with the majority of that panel 14-2, to approve esketamine only for people who have treatment-resistant depression.

For more than 20 years, I have researched illegal drug use and addiction. As a medical anthropologist, my work is oriented to understanding the perspectives and behaviors of people actively using illegal drugs. My research often involves fieldwork, which means participating in the lives of people as they go about their everyday routines. This has given me a personalized and practical outlook on illegal drug use. Many of the people I currently interview are heroin injectors who first started opioid use by misusing prescription drugs.

Not a street drug

But many drugs, especially those for the treatment of mental illness, have powerful effects on the central nervous system. How the drug is distributed and administered must minimize risk. What if the drug is addicting?

Some reports about esketamine have sensationalized this issue by referring to ketamine as a highly addictive street drug. In my research, this is not true. First, ketamine use is rare. The last time I interviewed a ketamine users was nearly 20 years ago and since its introduction in 1964, there have been no significant trends or outbreaks in its diversion or use.

Not all illegal drugs are sold “on the street.” Street drugs are staples of the illegal drug economy, which is run by drug trafficking organizations. Prescription opioids, heroin, cocaine, and marijuana are street drugs sold in open-air drug markets, where such markets exist. Hallucinogens and exotic, designer and other less popular drugs are rarely available in these settings. They simply do no appeal to enough users to make them profitable for drug traffickers to supply. Ketamine has always been in this second group. Why?

Is it addictive?

Ketamine is short-acting – between two and four hours – and produces euphoria, sustained pain relief and sedation mixed with powerful hallucinogenic effects. Taking this drug can be very unpleasant. Out-of-body experiences, time perception distortions, tunnel vision and dissociation are common. These effects limit the popularity of ketamine and make it difficult to use habitually.

A person can take heroin everyday and function. Ketamine is disruptive.

Promising new drug for treatment-resistant depression – esketamine
Esketamine is taken as a nasal spray. Kirill Linnik/

Another reason that ketamine isn’t popular on the street is that users do not have to keep using it to avoid withdrawal. There is no withdrawal syndrome associated with ketamine; when people stop using it, they do not get sick. This is actually a benefit, because fear of withdrawal is often a major motivation for the continuation of drug use. Unlike street drugs, its appeal is limited and its addiction liability is comparatively low.

On balance, the profile of ketamine is more like LSD than cocaine or opioids. People do not get addicted. This does not mean that ketamine or esketamine is safe. Its access should be restricted and use monitored by a physician. The manufacturer is placing important restrictions on the drug. It will not be available at local pharmacies and never for take-home use. A person receiving the treatment, which was developed by Johnson & Johnson and delivered as a nasal spray, will be under observation and care of a health professional trained in the therapy. The drug will be given in an office or approved health center, and the patient will not be allowed to drive until the day after treatment.

Given its effectiveness and the proposed risk evaluation and mitigation strategy, the benefits outweigh the risks of esketamine for the treatment of depression that has not responded to other treatments. Like any new treatment, as manufacturers make this product available, monitoring it will be important to make sure the benefits outweigh the costs. People living with the misery of treatment-resistant depression need more options, and this drug should help.

African-American women with HIV often overlooked, under-supported

The face of HIV in the United States has long been white gay men, even though the epidemic has had a devastating and disproportionate impact on African-American communities.

This is especially true among women; 60 percent of newly diagnosed cases of HIV in women in 2017 were African-American. Yet, African-American women’s voices are notoriously absent from the national discourse on HIV.

Largely invisible to a fractured health care system, these women are often breadwinners and matriarchs whose families count on them for support and care.

Treatments to help people who are HIV-positive manage their illness and survive into older age have improved greatly, yet the unique health needs of African-American women living and aging with HIV – estimated at about 140,000 – are often ignored.

While many are actively taking medication and receiving care, some do not know their HIV status. After diagnosis, many have difficulties managing their HIV, which can contribute to their other health challenges.

I have been working on collecting oral histories from many older HIV-positive women in the Washington D.C. area, where I live and research. It is my hope that by focusing on the voices of African-American women themselves, we as a country are able to better understand the profound impact that HIV has had on black life.

HIV and African-Americans

Many believe the HIV epidemic in the United States is nearing an end, in part because increased funding, targeted prevention efforts, and better treatment have resulted in drastic reductions in new HIV-positive cases. Even President Trump, in his recent State of the Union address, discussed his goal of ending HIV by 2030. I am an HIV researcher, and I can say this is totally unrealistic, especially for African-Americans.

Despite comprising only 12 percent of the overall U.S. population, African-Americans represent 43 percent of all persons with newly diagnosed HIV and 42 percent of all people living with HIV. African-Americans living with HIV are nearly 10 times more likely to be diagnosed with AIDS and over six times more likely to die of complications of AIDS than their white counterparts.

African-Americans are also at a higher risk for other health conditions, which can make managing HIV infection more difficult. For instance, African-Americans are twice as likely to die from heart disease and 50 percent more likely to have high blood pressure than whites.

In Washington D.C., a place filled with public health experts and policymakers, the HIV prevalence rate is the highest in the nation, exceeding the World Health Organization definition of a generalized epidemic. African-Americans represent a staggering 75 percent of all HIV cases in D.C.

African-American women with HIV often overlooked, under-supported
Toya Tolson of Prince George’s County suffered trauma and abuse as a child only to battle addiction as an adult. She is one of more than 100,000 African American women who are aging with HIV. Aamir Khuller, CC BY-NC-SA

HIV in Washington D.C. is a regional epidemic, and crosses the jurisdictional border into Prince George’s County, Maryland. The sprawling suburbs of Prince George’s County are well known for their ranking as one of the wealthiest African-American-majority counties in the nation, but with HIV rates that are four to 10 times higher than those of white adults.

The high rates of HIV in Washington D.C. and Prince George’s County reflect a growing public health crisis in the United States, where the disproportionate burden of HIV is increasingly concentrated in the U.S. South. Southern states, where 55 percent of African-Americans live, have the highest rates of new HIV-positive diagnoses, the highest percentage of people living with HIV, and the lowest rates of survival for those who are HIV-positive.

Government investment in the domestic response to HIV tops more than US$26 billion per year, yet these health inequities in HIV for African-Americans continue to persist. These inequities are due in part to abstinence-only funding to schools with large minority populations and HIV-specific criminal laws, which undermine the health and well-being of African-Americans and perpetuate systems of inequity. Systemic racism in resource distribution, such as concentrated poverty and health care and funding disparities is also a significant driver of the epidemic within African-American communities.

Since the beginning of the epidemic in the 1980s, African-American women have carried a large burden of HIV, and more than 60,000 lost their lives. But not everyone died. My project of personal narratives of these women suggest that they live with multiple uncertainties brought on by HIV. Many worry about how their health, disability, and eventual death will impact their roles as mothers, grandmothers, daughters, sisters and wives.

Lives of suffering, strength and survival

African-American women with HIV often overlooked, under-supported
Shawnte’ Spriggs considers herself fortunate to be alive. Aamir Khuller, CC BY-NC-SA

Shawnte’ Spriggs’ story is typical of many African-American women living with HIV whom I spoke to. Many suffered trauma and abuse as children. Like everyone, however, she has her own unique story.

“My family stories are not pretty,” said Spriggs, 45, who grew up in northeast Washington D.C., in a neighborhood with open-air drug markets, crime and gang violence. “My mother had a very bad temper. If she had a bad day, or someone teed her off, or one of her boyfriends did something to her, I was abused pretty bad.”

Her father was around only intermittently. She later learned the reason for his disappearances: He was often in prison.

Looking for love and craving protection from her mother, she turned to her godbrother, a caring guardian whom she later married.

Three months into their marriage, beatings began. The first was in the middle of the night. She woke suddenly. Her ex-husband was still asleep but sat up as if he were awake and punched her in the face. They both laughed about it in the morning, as if it had been an accident.

The abuse continued.

Eventually Spriggs escaped the marriage. She moved to another state and created a rewarding life. She even found love again, and remarried. She changed careers. She also became an evangelist, traveling for religious conferences frequently.

In 2010, Spriggs accepted an invitation to speak at a women’s conference in Lynchburg, Virginia. The conference offered health screenings. Some of the women invited her to take an HIV test with them. “Sure, why not?” she thought, wanting to set an example for the young women attending.

The last thing she expected was to test positive.

Her initial reaction was that she was going to die. She researched to learn more about HIV and began to realize that many people in her life probably died of it even though it was being labeled as something else in the community. She was terrified, especially because she feared returning to the pain and trauma from her past.

“I was so afraid of going to a dark place, from my childhood. I know my triggers,” Spriggs said.

She took action, signing herself up for both inpatient and outpatient mental health care, which helped her with her healing process. She attended HIV support groups, where she was the only woman among gay men.

Spriggs counts herself fortunate. She knows that many others have fewer resources, more responsibilities, and a lack of accessible and culturally appropriate care.

Editor’s note: Read the stories of other women living with HIV in tomorrow’s edition of The Conversation.

Hundreds of genes linked to blindness could lead to new therapies

Inherited diseases of the eye account for at least 2 million cases of blindness worldwide. A few hundred genes that cause eye disease have been identified, but in many cases the cause is unknown because not all eye disease genes have been identified.

As a result, genetic testing is only able to determine the mutation responsible for blindness in only 50 to 75 percent of blind children and young adults.

As an eye doctor and researcher, I am frustrated at the lack of treatments for my patients with genetic forms of blindness such as retinitis pigmentosa, Stargardt disease and age-related macular degeneration. To address this problem, my lab launched a study of genes required for normal eye formation and function. We discovered 347 genes that, if mutated, cause blindness in laboratory mice. Of these, 261 had never been linked to vision loss before our study, which we published recently in the journal Communications Biology.

Knockout mice help identify more blindness genes

Researchers first identified eye disease genes in the late 1980s by studying families in the United States with inherited forms of retinitis pigmentosa, a disease of retinal cells called rod photoreceptors in children and young adults, which leads to eventual blindness. Since then, more and more families have been studied to add to the list of blinding mutations in people.

To figure out which genes cause blindness, we took advantage of something called knockout technology. Researchers engineer a knockout mouse by deleting both copies of any single gene. This effectively deletes it from the mouse’s genome. Abnormalities result, and they provide clues as to the function of the “knocked out” gene. The mouse genome is similar to that of humans and contains roughly 22,000-25,000 genes. So far, scientists around the world have knocked out about about 7,000 genes in mice, and the process of studying these mice is ongoing.

The invention of knockout mouse technology in the 1990s led to the identification of eye disease genes by studying the eyes of mice with targeted deletions. The International Mouse Phenotyping Consortium (IMPC), which consists of more than a dozen mouse biology centers across North America, Europe and Asia, aims to create a knockout mouse for every gene in the mouse genome. The IMPC has created and carefully examined over 4,364 knockout mice.

By analyzing the recorded data from the mouse eye exams at all IMPC centers across the globe, my colleagues and I found that 347 of these knockout mice, each one representing a single deleted gene, had eye abnormalities as determined by trained ophthalmic experts. The abnormalities sometimes involved the anterior structures of the eye, such as the eyelids, cornea and lens, and sometime posterior structures, such as the retina and optic nerve.

Hundreds of genes linked to blindness could lead to new therapies
Researchers have discovered genes controlling all parts of eye development are linked to heritable eye diseases. solar22/

Testing mouse eye disease genes in humans

Since the mouse and human genomes are similar, it’s highly likely that these newly identified genes, if mutated, also cause human eye diseases. The next step is to study these newly implicated mouse genes in blind human patients. Specifically, we will analyze the genomes of patients whose prior genetic testing could not link their condition to one of the previously known eye disease genes.

The addition of hundreds of new eye disease genes in this IMPC study will help eye doctors like me around the world provide more precise genetic diagnoses to our patients. To validate these genes in humans, we plan to create a panel of these new 261 genes that can be scanned for mutations.

Furthermore, the knockout mice themselves will serve as publicly available research models for the newly discovered eye disease genes. All of these knockout mice are available to all researchers and can be ordered from the IMPC repository for additional scientific studies and therapeutic discoveries. These mouse models can be used to test new medications, gene therapies and stem cell approaches.

Knockout mice teach us about the genetics

The scientific discoveries of the IMPC are quickly advancing our understanding of the thousands of genes and molecules that underlie many human disease processes. In each organ system of the body, researchers are finding many genes that have never been linked with disease. The results of the IMPC project, including the eye disease genes, could advance the diagnostic capability, and identify new targets for novel therapies.

I hope that eye doctors at major universities and eye centers will cross reference our list of 261 new eye disease genes from mice with the genetic sequence of their human patients in whom they found no mutation that causes disease.

We hope our list of genes will guide our colleagues to the genetic culprit in many cases and provide both a specific diagnosis and a path forward toward eventual treatment for those families afflicted with inherited forms of blindness.

Confusing and high bills for cancer patients add to anxiety and suffering

Weeks after my father passed away from cancer in 2010, my newly widowed mother received a bill for US$11,000.

Insurance retroactively denied a submitted claim for one of his last chemotherapy treatments, claiming it was “experimental.” All of the prior identical chemotherapy treatments he had received had been covered, and the doctors had received pre-authorization for the treatment.

Was it suddenly experimental because it was not prolonging life anymore? Was it a clerical error, with one insurance claim submitted differently than the others?

As my mother and family grieved, we had this bill looming in the backs of our minds. We took turns calling the insurance company and the hospital billing office, checking websites, and deciphering billing codes on various pieces of paper.

Advances in cancer treatments have improved patient outcomes overall, but many of these interventions have increased costs of care. Even when care is “covered,” the definition of “coverage” can include high deductibles, copayments, coinsurance, and surprise out-of-pocket bills for patients. As one participant in a recently published qualitative study of cancer survivors told us, “You just have to call both parties and figure out, what are you chargin’ me for? Plus … you’re getting billed for months ago.”

By the time patients receive these delayed bills, they may be unable to recall the particular visit in question, which makes it exhausting for them to manage their finances and diagnosis. The problem is so significant that the National Cancer Institute has a term for this: financial toxicity.

A scary disease, an opaque system

Confusing and high bills for cancer patients add to anxiety and suffering
Cancer is one of the scariest and most expensive diagnoses a patient can receive. Sasa Prudkov/

In the U.S., cancer is one of the most expensive diseases to treat; only heart disease costs more. This cost burden is often passed on to patients.

And to make matters worse, lack of transparency about cost and coverage can be confusing. Seemingly arbitrary changes in insurance decisions can contribute to patients’ financial toxicity, or the hardship, psychological stress and behavioral adjustments associated with costs of care. For example, some patients have unexpected bills after they receive a diagnosis or abnormal result on a screening test.

In these cases, care that was previously categorized as preventive (and free from out-of-pocket costs) can become a diagnostic or surveillance test, with associated fees. Other patients are surprised when they receive a bill for physician time as well as a hospital facility fee. It is difficult for patients to keep track of all of these changes and adjust cost expectations.

The impact of high care costs is substantial. People with high out-of-pocket costs are less likely to receive necessary care, which can compromise cancer treatment and may affect overall or cancer-specific mortality. In a recent study, almost a third of adults said they delayed or avoided care due to costs.

A patient participant in a study we conducted talked about the time she spent navigating the billing process, commenting, “The billing was extremely daunting. I kept a three-ring binder that was three inches thick … tried to match things up. It was a mess.” That time and effort could be spent healing or engaging in valued activities, she relayed to us.

Hidden costs of care

In addition to direct costs of care, there are indirect costs of care, such as fees for transportation, parking, housing when needed, and the time spent managing the financial aspects of care on top of treatment.

My father had to pay between $18 and $30 per day just to park at the hospital in New York City where he received his treatments, depending on how long he stayed. This parking fee was on top of tolls ($15) and the time spent traveling to and from the hospital. For him, this meant anywhere from 45 minutes to two hours, depending on traffic and road conditions. Transportation and parking costs are typically not covered by insurance, though some hospitals, health centers and nonprofit organizations offer assistance with these indirect care costs.

Many other patients have to take time off work while they are undergoing cancer treatment or follow-up care. Cancer patients who are unemployed may even have lower survival rates. One patient in our study commented, “It takes me two-and-a-half hours to get here. I was coming every month, then every two months. Now I’m every three months. Eventually, I go to six months, but I have to take off work every time to come.” Another patient stated, “My vacation and sick time ran out … I had to go on disability.”

Policy suggestions

Confusing and high bills for cancer patients add to anxiety and suffering
A cancer patient and her doctor discuss her treatment. Talking with doctors about costs may make a difference. Rido/

Although addressing out-of-pocket care costs for patients requires multiple systemic changes, there are strategies that can help.

First, patients and their clinicians can discuss the costs of care and create cost-saving strategies. Patient-clinician cost discussions can reduce overall costs to patients, but many clinicians are hesitant to talk about costs with patients.

If there is more than one treatment option available with equal effectiveness data, patients can ask, “is there a difference in price between options”? Developers of patient-centered decision aids can also add the relative costs of treatments so that patients can weigh cost along with other aspects of treatment to support their choice.

Health care institutions may be underutilizing social workers, financial navigators and other care center resources. Social workers, financial navigators and other care center resources staff with adequate training that promotes patients’ access to care and assistance can help manage their out-of-pocket expenses. This process can yield positive outcomes for both patients and health care institutions.

Less may be more

Sometimes, treatments are not needed and may add burden to patients. For example, a shorter duration of radiation for early stage breast cancer works just as well as longer durations; chemotherapy might not benefit some patients at earlier stages of cancer or some older adults; and some scans may be excessive.

Until we change norms and engage patients, clinicians and systems to weigh the pros and cons of care that is considered unnecessary or even harmful, many patients and clinicians might fear less aggressive treatment. There’s also the Choosing Wisely campaign which is designed to help by summarizing evidence in plain language and recommending commonly overused interventions.

Finding sustainable solutions to reducing cancer-related financial toxicity requires a collaborative effort between doctors, patients, policymakers, health insurance companies and health care institutions. Easing the cognitive burden associated with the financial stress that comes with cancer care can lead to better outcomes for cancer patients’ health and quality of life.

Research coordinator Nerissa George, MPH, contributed to this article.

Why it’s so difficult for scientists to predict the next outbreak of a dangerous disease

A two-year-old boy in rural Guinea died of Ebola in December 2014. Over the next two years, almost 30,000 people in West Africa would be infected with the Ebola virus.

Why, unlike the previous 17 Ebola outbreaks, did this one grow so large, so quickly? What, if anything, can be done to prevent future outbreaks? These questions, along with many others, are at the heart of the nascent scientific field of outbreak forecasting. And the stakes couldn’t be higher. In January, the World Economic Forum called pandemics one of the greatest risks to business and human life.

Over the last several centuries, scientists have become ever better at predicting many aspects of the world, including the orbit of planets, the ebb and flow of tides and the paths of hurricanes. The ability to understand natural and physical systems well enough to make accurate forecasts is perhaps one of humanity’s greatest achievements.

Much of this success at forecasting begins with Isaac Newton’s fundamental insight that there are unchanging universal laws that govern the natural phenomena around us. The ability to rapidly perform large calculations has fostered the Newtonian perspective that, given enough data and computing power, most complex phenomena can be predicted.

There are, however, limits. As scientists who study these kinds of predictive systems, we doubt that it will be possible to predict exactly what will happen next in a disease outbreak, because the most important variables can change so much from one outbreak to another.

This is why, as with weather forecasting, gathering real-time data is likely essential for advancing the scientific community’s ability to predict outbreaks.

Why it's so difficult for scientists to predict the next outbreak of a dangerous disease
A health care worker gets decontaminated after carrying a baby, suspected of dying from Ebola, in the Democratic Republic of Congo on Dec. 15. REUTERS/Goran Tomasevic

Capricious epidemics

The idea that scientists can model epidemics is based on the notion that the trajectory of each outbreak is predictable because of its intrinsic and unchanging properties.

Say a disease is caused by a transmissible pathogen. The infectiousness of that disease can be encapsulated in a number called the “basic reproductive ratio,” or R0, a number describing how widely a pathogen is likely to spread in a given population.

If epidemiologists know enough about a pathogen’s R0, the hope is that they can predict aspects of its next outbreak – and hopefully prevent small-scale outbreaks from becoming large-scale epidemics. They might do this by mobilizing resources to areas where pathogens have especially high R0 values. Or they might limit interactions between the carriers of disease and the most susceptible members of a given society, often children and the elderly.

In this way, R0 is interpreted as an immutable number. But modern studies demonstrate that this not the case.

For example, consider the Zika virus epidemic. For this disease, R0 ranged from 0.5 to 6.3. This is a remarkable span, ranging from a disease that will dissipate on its own to one that will cause a long-term epidemic.

One might think that this broad range of R0 values for Zika stems from statistical uncertainty – that maybe scientists just need more data. But that would be mostly incorrect. For Zika, myriad factors, from climate and mosquitoes to the presence of other related viruses like Dengue and the role of sexual transmission, all lead to different R0 values in different settings.

It turns out that the features of an epidemic – the pathogen’s contagiousness, rate of transmission, availability of vaccines and so on – change so rapidly during the course of a single outbreak that scientists are able to predict dynamics only within the course of that outbreak. In other words, studying the Ebola virus disease outbreak in April 2014 may help scientists to understand an Ebola outbreak in that same setting the next month, but it’s often much less helpful for understanding the dynamics of future Ebola epidemics, such as the one that happened in May 2018.

Epidemics often aren’t neat and bundled phenomena. They are noisy occurrences where many variables play essential, but shifting, roles. There is no underlying truth of the disease – only an unstable collection of details that vary, often becoming entangled, as the disease spreads.

Why it's so difficult for scientists to predict the next outbreak of a dangerous disease
Amid a measles outbreak that has sickened people in Washington state and Oregon, lawmakers heard public testimony on the bill on Feb. 8 that would remove parents’ ability to claim a philosophical exemption to opt their school-age children out of the combined measles, mumps and rubella vaccine. AP Photo/Ted S. Warren

Better predictions

If scientists aren’t confident that they can understand epidemiological systems well enough to predict the behavior of related ones, why bother studying them?

The answer might reside in what we call a “soft physics” of prediction: Scientists should stop assuming that every outbreak follows the same rules. When comparing one outbreak with another, they should keep in mind all of the contextual differences between them.

Why it's so difficult for scientists to predict the next outbreak of a dangerous disease
The H1N1 influenza virus. CDC

For example, biologists have uncovered many details about influenza infections. They know how the viruses bind to host cells, how they replicate and how they evolve resistance to antiviral drugs. But one epidemic might have started when a large population used public transportation on a certain day of the month, while another might have been initiated by a congregation at a religious service. Though both outbreaks are rooted in the same infectious agent, these and many other differences in their particulars mean that scientists may need to reframe how they model how each progresses.

To understand these particulars better, scientists need significant investments in real-time data. Consider that the National Weather Service spends over US$1 billion per year gathering data and making forecasts. The CDC spends only a quarter as much on public health statistics and has no dedicated budget for forecasting.

Disease surveillance remains one of the highest-stakes areas of science. A careful consideration for unique circumstances underlying outbreaks and more responsible collection of data could save thousands of lives.

To end the HIV epidemic, addressing poverty and inequities one of most important treatments

To end the HIV epidemic, addressing poverty and inequities one of most important treatments
Homelessness is a major driver of HIV/AIDS. Andrew Marcus/

In his State of the Union speech, President Trump called for ending the HIV epidemic in the United States within 10 years. Health and Human Services Secretary Alex Azar and senior public health officials stated that the government plans to focus on highly impacted areas and getting drugs to people at risk.

I am a social scientist with over 10 years of expertise in the area of health disparities. My research interests include understanding and addressing disparities in HIV and cancer outcomes, particularly among immigrant and minority populations, using a social determinants of health framework.

While remarkable progress has been made in the fight against HIV/AIDS, ending the epidemic will likely take longer than 10 years and will take more than drugs. That’s because the main driver of the disease has more to do with social inequity than with the virus alone.

The overall annual number of new HIV diagnoses has remained stable in recent years in the U.S., but this has not been the case for all groups. In fact, data from the Centers for Disease Control and Prevention reveal that major racial, ethnic, socioeconomic and even geographical inequities still exist. These inequities exist at every step in the HIV care continuum, from testing to mortality.

This means that there are gaps along the continuum and these individuals are being lost at each step, including HIV testing and diagnosis, linkage to appropriate HIV care, support while in care, access to antiretroviral treatment, and support while on treatment. These gaps exist due to barriers such as poor access to services, poverty, food insecurity and homelessness, and stigma and discrimination.

A HIV hot spot: The South

To end the HIV epidemic, addressing poverty and inequities one of most important treatments
A nurse pricks the finger of a young person to draw blood to test for HIV. Adam Jan Figel/

Among the CDC’s most distressing recent findings: More than half of new HIV diagnoses in the United States occur in the South. The heavy burden of HIV in the South is driven by factors such as concentrated poverty in cities, suburban areas and rural counties, high levels of unemployment, inadequate local health care infrastructure, and a lack of access to health insurance and quality health care services. Other important factors include increased stigma and discrimination toward those living with HIV. This can lead to people being afraid to get tested or seek treatment for fear that someone may find out they have HIV.

Gay and bisexual men account for 66 percent (25,748) of all diagnoses and 82 percent of HIV diagnoses among males. And, although African-Americans represent 13 percent of the U.S. population, they account for 43 percent (16,694) of HIV diagnoses. Likewise, Latinos represent 18 percent of the population but account for 26 percent (9,908) of HIV diagnoses.Racial and ethnic minority women account for a disproportionate share of diagnoses of HIV infection among women.

An arsenal beyond the medicine chest

HIV interventions that focus narrowly on pharmaceutical or drug innovations alone or individual behavior change cannot effectively address the magnitude and complexity of the HIV epidemic, as I explain in my recently published article with co-researcher David R. Williams, Ph.D. at Harvard T.H. Chan School of Public Health, in Public Health Reports. What we need most urgently today is a new generation of rigorously evaluated, cost-effective HIV interventions focused on the fundamental contextual factors for disease. These factors include:

  • access to adequate housing
  • access to quality health care and health insurance
  • access to child care
  • education, employment status, gender equality and income.

These factors are known generally as the social determinants of health (SDH) and have been viewed as the drivers of health for decades by many public health experts.

To cite a few examples, in one scientific study, structural community factors, such as poverty and poor employment opportunities, limited access to health care resources among women in the Deep South. In addition, stigma, transportation challenges, and access to illicit substances impacted health-seeking behavior and decision-making, and the ability to engage in HIV care.

Similarly, another study found that homeless individuals were more likely to be uninsured and less likely to adhere to their HIV anti-retroviral medication, demonstrating that housing is an important mechanism for improving the health of this vulnerable group.

Moreover, racial/ethnic stereotypes are deeply embedded in American culture and, whether consciously or not, can adversely affect the care that providers give to their patients. Evidence indicates that interventions that address implicit racial bias among providers can improve the quality of care and reduce racial/ethnic disparities in HIV outcomes.

With this scientific evidence in mind, it is perhaps unsurprising then, that despite three decades of public education and clinical campaigns, more than half of all the new infections in the entire region of North America, Western Europe and Central Europe occur in the U.S.

Make things fair

To end the HIV epidemic, addressing poverty and inequities one of most important treatments
Tents for homeless people in San Francisco, Calif., where a lack of housing is a rising crisis. Gov. Gavin Newsom recently announced a plan to create new housing to provide homeless people with secure housing. Eric Risberg/AP Photo

So what will it take to end the epidemic in the U.S.?

Put simply, to fight HIV, we need to address poverty and social inequity. This approach is the vital game-changer needed to eradicate the HIV epidemic in the U.S. Whenever feasible, social determinants need to be incorporated into behavioral and biomedical strategies to increase their likelihood of success. A new generation of HIV interventions focused on the fundamental SDHs should be the centerpiece of efforts to address HIV-related disparities.

There is growing scientific evidence documenting that interventions that address poverty and inequities in social and living conditions can be effective in reducing risks of HIV infection. Numerous studies reveal that improving education and affordable housing can reduce incidence rates of HIV and AIDS, because low levels of education and unstable housing have been found to decrease social stability and increase HIV risk behaviors.

These studies reveal that interventions that strengthen women’s income, housing stability and gender empowerment are associated with improved psychological well-being, economic productivity and reduced HIV risk. Improving access to care and enhancing quality of care can also contribute to reducing disparities in the incidence of HIV.

It is time to recognize that every government action has the potential to affect health and health equity, including policies dealing with finance, education, housing, employment, transportation and health. Economic studies also support the fact that most rigorously evaluated interventions focused on SDHs have been shown to be cost-effective and save society money in the long run. It is therefore important to integrate this Health in All Policies approach to have the widest impact on the HIV epidemic.

I believe Americans must commit to making it clear to our leaders and to all Americans that all sectors of society gain when we invest in tackling inequities in the most vulnerable areas. HIV/AIDS is not a partisan issue. Political will – and good will toward our most vulnerable fellow citizens – can engender a national “culture of health” that shatters boundaries, equalizes access, and makes HIV/AIDS a fading spectre from the past.