The HIV Paradox
By Tony Rehagen
It was July of 2015, the year he turned 29, when Daniel Driffin decided it was time to come out.
Driffin had openly declared that he was gay as a high schooler in Rochester, New York. After he went off to study biology at Morris College in small Sumter, South Carolina, he dedicated himself to HIV awareness, prevention, and care for gay black men.
Still, when he contracted human immunodeficiency virus in 2008, Driffin didn’t feel comfortable telling anyone about his disease. He knew well the stigma HIV and AIDS carries, especially among Southern blacks, many of whom have been steeped in the religious conviction that being gay is a sin and that the disease is a scarlet letter.
“Living in South Carolina at that time, I didn’t have the positive gay community to pull strength from,” he says. “Until you feel safe, you’re hindered in the process of coming out to be your true self.”
Driffin eventually found that strength and security after he moved to Atlanta to work with a community organization providing rapid testing to young, gay black men in 2010. And last summer, after five years of living and working in Fulton County, Driffin and two friends opened up about their own HIV status. Driffin now cochairs the Fulton County Task Force on HIV/AIDS alongside Wendy Armstrong, professor of infectious diseases at Emory’s School of Medicine.
“Atlanta is one of the largest cities in the South,” says Driffin. “People who can’t be themselves in their own little towns flock to Atlanta. Here, you’re one of many instead of one of a few. You’re able to be yourself.”
Yet, Driffin says that even in a large, relatively gay-friendly Southern city like Atlanta, a deeply rooted shame prevents many black gay men from admitting they have HIV. He wasn’t surprised this past May when researchers at Rollins School of Public Health published a study in the journal JMIR Public Health and Surveillance finding that while about 15 percent of gay and bisexual men in the US have HIV, the rates of infected men who have sex with men (MSM) in some Southern cities are twice as high as the national average.
Although the South is generally known as a hot zone for HIV/AIDS, the Emory study, led by Eli Rosenberg, assistant professor of epidemiology at Rollins, was the first to break down HIV rates for MSM by state, county, and metropolitan area.
“The US Census does not capture MSM or gay men, so we couldn’t calculate the rates,” says Rosenberg. “The CDC had produced a national number [of infected MSM], but there was no subnational number. Everything below that was darkness. When we wanted to look at states and counties, we were at a loss.”
Rosenberg’s team’s solution was to collect data from the Centers for Disease Control and Prevention (CDC) on nationwide HIV infection and divide those numbers by MSM population estimates from another recently published Emory study.
The results were staggering. According to Rosenberg’s research, six US states exceeded the national average of MSM diagnosed with HIV in 2012—and all of them were in the South. Of the top 25 metros in terms of prevalence, 21 were south of the Ohio River. And the frequency surpassed 25 percent in five of those cities—Jackson, Mississippi (39.5 percent); Columbia, South Carolina (29.6); El Paso, Texas (28.5); Augusta, Georgia (26.5); and Baton Rouge, Louisiana (25.4).
And while Atlanta, which includes Sandy Springs and Roswell, scored a relatively low 16.4 percent of MSM with HIV, Rosenberg is quick to offer perspective, saying that although the rate is 10 percent higher in Augusta, the Atlanta metro area has 18 times more cases—its percentage is diluted by all of the outlying counties lumped into the region. A closer look reveals that Atlanta metro counties show a significant uptick in prevalence—with Clayton County at 49 percent, DeKalb at 24 percent, and Fulton at 22 percent.
With a more detailed picture of where gay and bisexual men are being diagnosed with HIV, experts and advocates are asking: Why the high concentration in the South?
Although Rosenberg’s study is purely epidemiological—based on available surveillance data—he says that the research naturally leads to some educated guesses about the reasons behind the trend. It could be that the South is, by and large, poorer and more rural, with worse transit and less access to adequate testing or care than in other parts of the country. Then there is the cultural and religious bias that abounds in the region—the stigma attached to homosexuality, HIV/AIDS, and—Driffin would add—being black.
The next step, Rosenberg says, is to incorporate other data resources that would break the map down further—by age, education, poverty, and race.Carlos del Rio, the Hubert Professor of Global Health and Medicine specializing in infectious diseases and codirector of the Emory Center for AIDS Research (CFAR), says Rosenberg is on the right track.
“It is clear that the major drivers of HIV infection are poverty, unemployment, lack of education and health insurance,” del Rio says. “Addressing HIV in the South requires us also to address the social determinants of health. If you add stigma, discrimination, and racism, you have a perfect milieu for high HIV rates.”
CLOSER TO A CURE?
While Rosenberg and his team are pinpointing where HIV is striking hardest so that they can better target prevention and treatment, other Emory researchers are making strides toward improving that treatment—and moving closer to a cure.
Less than a month after the Rollins epidemiology study was released, the National Institutes of Health (NIH) announced that it was awarding a five-year, $35.6 million grant to the Emory Consortium for Innovative AIDS Research in Nonhuman Primates (CIAR-NHP). The consortium is a collaboration of scientists and investigators from an array of disciplines—from immunology to pathology to biostatistics—who’ve come together with the common goal of developing an effective, lasting vaccine for HIV.
“It’s an indication of the quality of research that is going on here,” says Eric Hunter, professor of pathology at the School of Medicine and the Emory Vaccine Center and the grant’s coprincipal investigator. “We have to be tackling this from multiple angles. This grant is going to give us the resources to really explore approaches that are going to move the vaccine field forward, because it involves multiple investigators from multiple viewpoints.”
“The type of research we’re doing is expensive in terms of animals and people,” adds Guido Silvestri, professor of pathology and laboratory medicine and division chief of microbiology and immunology at Emory’s Yerkes National Primate Research Center. “You’re not going to cure AIDS with a team of three people. When you have this type of support from NIH, this type of funding, you have some freedom.”
The grant’s other coprincipal, Rama Rao Amara, professor of microbiology and immunology and a researcher at Yerkes, says the team will focus on the twofold goal of cultivating a vaccine that will prevent HIV and finding a long-term cure for people who are already infected.
The task begins at the Emory Vaccine Center and Yerkes, where researchers are working with simian immunodeficiency virus (SIV), HIV’s nonhuman primate cousin, and other SIV/HIV hybrids to simulate the virus in people. In his 16 years at Emory, Amara has worked closely with former fellow faculty member Harriet Robinson on the groundbreaking HIV vaccine that uses human proteins to boost the body’s output of T cells, which attack and kill the virus. That inoculation, shown to be 60 to 70 percent effective, is now in the early stages of human clinical trials.
Meanwhile, Amara and his colleagues have moved on to look at an oral vaccination using a probiotic found in dairy designed to prevent infection at the point of exposure—a key distinction, especially for gay men who contract the disease through intercourse.
“The MSM population is the major population affected,” says Amara. “They need to have a response in the rectum. Most of the vaccines we use are delivered by veins, which doesn’t induce a strong immune response in the rectum. The way to do it is through the oral route.”
Amara says that one of the major obstacles in delivering an HIV vaccine through the mouth has been trouble getting the dose past the acid bath in the stomach en route to the rectum. “This vaccine is designed to survive that acidic environment,” he says. Preliminary studies of this oral vaccine have produced promising results in mice, and Amara is working toward the next phase of testing on primates.
The consortium is gearing up to tackle other challenges in effective HIV vaccination. These include balancing immune cells and CD4 T cells, also known as T-helper cells, which the virus tends to target; finding a way to help protective antibodies live longer and be more effective; packing new immunogens into the vaccines that can direct the antibody response at specific parts of the virus; and finding other methods of activating killer T cells at the points of the virus’s entry.
“There is a small window of opportunity for vaccines early on after exposure,” says Amara. “Initial infection is initiated by a few cells. Transmission efficiency of HIV is very poor—only one in 100 to 500 mucosal exposures result in transmission. HIV is very inefficient, and after it infects, it is believed that the initial infection only occurs in a few cells. If you can have immune responses at the point of entry, you have a high chance of success.”
Beyond the immunization and rapid response, Amara and the research team will also be looking into long-term treatment for people already chronically infected. Currently there are drugs that can control HIV, but they are unable to chase it completely from the body. That’s because the virus hides on immune cells that are dormant. When a patient is temporarily taken off of medication, due to side effects or lower levels of HIV, those cells jump out of their reservoirs and multiply rapidly.
“So these people have to be on drugs for the rest of their lives,” says Amara. “We started to look at how we could reduce or eliminate the reservoirs and how we could kick the virus out of those reservoirs.”
This particular strategy has become known by the catchy nickname “kick and kill.” One idea is to block the molecule PD-1, which hinders immune response. The result of this approach is twofold: It makes “killer” CD8 cells stronger, and could possibly stimulate the immune cells where HIV dwells, effectively jarring, or “kicking,” the virus out of hiding and into the open where it can be killed by antiretroviral therapy and killer cells.
“Kick and kill” has been tested on SIV-infected monkeys, and results showed promise—a quicker suppression of the virus and more active T cells to attack it. But the realization of that early promise is probably still years of trials, testing, and retesting away.
“Vaccine development is a slow process,” says Hunter, who also is codirector of the Emory Center for AIDS Research and a Georgia Research Alliance Eminent Scholar. “We know that the development of a vaccine is not going to happen in the next five years. Even at the most optimistic, we’re still talking seven to 10 years before they become widely available. That’s why we have to move forward with a more effective prevention message in the affected communities.”
WORD ON THE STREET
With a brighter spotlight illuminating the areas where HIV is most affecting gay men in the South, what’s happening on the prevention and awareness front?
In Atlanta, faculty from Rollins and the Emory School of Medicine are dedicated to finding the answer as part of the Fulton County Task Force on HIV/AIDS. Wendy Armstrong, professor of medicine specializing in infectious diseases, now cochairs the organization created by the Fulton County Board of Commissioners in 2014 to call attention to the Southeastern health crisis that Rosenberg’s study would later zoom in on. The county alone was seeing 5,700 infected patients each year, among the highest of any county in the country. And that number was growing. As a result, the board created the task force to make recommendations on improving access to treatment and prevention.
“Our mission was to develop a blueprint to combat AIDS in Fulton County,” says Armstrong, who was elected cochair of the task force alongside Driffin. Released last year, Phase I of the task force set forth four broad goals: A reduction in HIV infections, better access to care and improved outcomes for infected patients, elimination of disparities in care, and a more coordinated response to the entire epidemic.
This June, the task force rolled out Phase II—a bold, aggressive action plan built around a list of 10 priorities.
They include eliminating the stigma attached to HIV in hospitals, places of worship, schools, the media, and government; eliminating barriers to care and medication; providing free, routine HIV testing in all health care settings and jails, as well as free and confidential screening for those at highest risk; providing pre- and post-prophylaxis for those not infected, condoms and lubricants for everyone, and syringe exchange and services for drug users; requiring accurate HIV and sexual health education in schools; and better access to housing, mental health services, and insurance for people with HIV.
Armstrong says Phase III, due to roll out this December, will include more details on cost and implementation. The common thread stitching together all of these priorities is “access,” a challenge that Armstrong says is not unique to Fulton County.
“HIV originally impacted the white, gay, male population,” she says. “They organized quickly into education and advocacy groups. They’ve done an impressive job of working on HIV in their own communities. Now the epidemic has moved into a population less well organized, without a voice.”
That silent population isn’t identified only by race. Armstrong points out that if you overlay a map of HIV concentration onto those showing hot zones for poverty and poor access to education and health care, the patterns are quick to emerge.
“It all overlays over the Southeast,” she says. “And these are people for whom HIV is not necessarily the top priority. They’re more worried about where they going to live, where they’re going to get their next meal.”
Armstrong adds that while Fulton County mirrors much of the Southeast when it comes to risk factors, a big difference is the level of support the HIV community is getting from its board of commissioners. “They’ve been very proactive about saying there is a problem,” she says. “I can’t emphasize enough how important that’s been. And they have shown a willingness to talk about some pretty politically unpopular things, like sex ed in schools and syringe exchange.”
Thanks largely to that support, Armstrong says she sees early progress in an increase in local media coverage and politicians’ willingness to talk about the subject, and she hopes that will spur neighboring counties to follow suit and eventually create a model for counties and local governments across the region. They are already drawing interest from Georgia and the city of Atlanta.
Zooming out for a more global view, Emory’s del Rio, CFAR codirector, was invited to speak at the Joint United Nations Programme on HIV/AIDS (UNAIDS) in June. He addressed the leadership meeting of “90-90-90 and Human Resources for Health,” the ambitious plan developed by UNAIDS targeting that by 2020, 90 percent of all people living with HIV will know their HIV status; 90 percent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90 percent of all people receiving antiretroviral therapy will have viral suppression.
“I am an optimist, and I am fortunate to have seen amazing developments in HIV during my lifetime,” del Rio says. “We discovered the virus, developed diagnostic tests, developed effective drugs, and launched the most successful public health program in the history of mankind, the federal President’s Emergency Plan for AIDS Relief. We have had tremendous scientific developments that put us in a position now to make a difference in the epidemic and maybe end AIDS by 2030.
“But I am also a realist, and I see donor fatigue around HIV/AIDS, competing priorities, and a more complicated funding environment. Our biggest challenge as a society is clear—we must strive for a world where there is no one living in extreme poverty, where access to education and health is a right, and where human rights are respected. If we do that, not only will we end AIDS, but many of the major scourges we suffer.”