HIV/AIDS: Fast-Track Cities and the Dream of 90-90-90

The Fast-Track Cities initiative represents a joint effort to address the global HIV and AIDS crisis in cities and municipalities around the world.

City and community leaders worldwide have committed to an initiative known as the Paris Declaration, which outlines a plan to eliminate the threat of HIV by achieving targets that include 90 percent of HIV patients being diagnosed, 90 percent of patients being on treatment and 90 percent of people living with HIV being virally suppressed. These statistical aspirations are often referred to simply as "90-90-90."

Attaining these numbers when it comes to HIV patients being diagnosed, treated and virally suppressed is viewed as a critical step toward eliminating HIV and AIDS as an international threat.

"Fast-Track Cities are, of course, those cities where we see some additional resources so that they can implement interventions to improve prevention techniques, make sure people are in care and assure that the delivery of care is ideal so that they can maintain viral suppression," said Christine Brennan, a nurse practitioner and educator with almost 30 years of experience in health care and HIV/AIDS education and training. "It's End the Epidemic, but it's targeting big cities."

Brennan said, at least in her own backyard of New Orleans—which is indeed on the list of cities that have signed the Paris Declaration—there remains room for improvement.

"The first thing we need to do is get people tested," she said. "We are still failing this to a level that is criminal."

The official numbers for New Orleans in terms of meeting the 90-90-90 goals are listed as 87-72-94. This means, according to the Fast-Track Cities site as of 2019, New Orleans lists itself as having an HIV population that is 87 percent diagnosed, 72 percent treated and 94 percent virally suppressed as of 2019, when those numbers were reported.

Having boots on the ground, Brennan questions whether these numbers reflect accurate data in the Crescent City.

"We have very limited testing in our ERs," she said. "As I tell people all the time, and they just kind of don't get it, there's probably 20 locations in the state of Louisiana that someone could walk into and be offered or easily ask for an HIV test with no pushback."

Doctors and providers who understand and value the role of STD/STI testing, in general, tend to have no problem providing screening to patients. Unfortunately for those seeking comprehensive sexual health services in Louisiana, those services can feel few and far between. In Southern and more conservative states, providers often refuse to perform HIV and other STD/STI tests, citing the inability or unwillingness to do so while totally avoiding culpability for their negligent behavior.

Patients seeking HIV and STD/STI testing in Louisiana often have to advocate extremely vocally with their own primary care providers, and many individuals around the country, in general, must go out of their way to obtain results from a complete or partial panel of tests.

Official channels and government-funded healthcare initiatives have their own pitfalls to work around. There's only so much money, time and energy to go around, so it makes sense that Federally Qualified Healthcare Centers (FQHCs) and cities like the ones that signed the Paris Declaration would stub their toes when it comes to certain aspects of HIV care, education and awareness.

Those efforts can be stalled by a general lack of interest combined with people being over inundated with information online and in real life. This is why it's so important for each of us to do what we can when it comes to HIV awareness, education and prevention.

Markalain Dery, D.O., MPH, FCOI lives and works in the New Orleans area, and said getting people to engage with HIV information and content can be a real challenge, even when bridging this particular gap is at the heart of the mission.

Dery works with Eric Griggs, M.D., and a team of content producers to create fun and informational cartoons and other mixed media content promoting information about HIV and other important health issues. He said a recent lesson in the nature of online content and the ability of important messages to go viral in the U.S. has left him wanting.

"I was at a [Fast-Track City] meeting watching these incredible countries present their data and how far ahead they are with being able to get to a point where we can eradicate HIV," Dery said. "Bruce Richman was there, and he's the guy who first coined U=U, and I was able to show him the videos firsthand. He loved them, and he put it out from his organization and on his personal Twitter, and the impact that it made was almost negligible. There were no increases in our YouTube views."

The term U=U stands for Undetectable=Untransmittable. It refers to a prevention method that is 100 percent effective as long as someone with HIV is taking their medicine and maintains an undetectable viral load, which occurs when the amount of HIV in the blood is so negligible the virus cannot be sexually transmitted.

"Here's arguably one of the most influential HIV educators, Bruce Richman, who coined the term U=U, putting out a statement that says, 'This is awesome content, you have to watch it.' And, not a click," Dery said with a reticent laugh.

This result shouldn't reflect on Richman or the dedicated efforts of Dery and other HIV/AIDS advocates, but it does paint a picture of the immense and formless monster that is HIV ignorance and disinterest in the public eye. On one hand, this reality helps to emphasize the importance of Fast-Track Cities and working toward the 90-90-90 goal internationally. On the other hand, public indifference stands in between the United States and the elimination of HIV.

The steep climb toward actual HIV awareness is all too real for people who work in the field.

How can Fast-Track Cities—as well as those cities and municipalities that have not yet signed the Paris Declaration—get on a faster track when it comes to HIV prevention, testing and treatment?

There's not one solution, but it's clear we need a more integrated and widespread system of HIV treatment and care if we are ever going to eradicate HIV. Unfortunately, one of the first vital steps in this goal is abstract, nuanced and unavoidably complicated.

Stigma surrounding HIV and those affected by it is at the core of many of the issues surrounding Fast-Track Cities. In states where the HIV situation is, in some ways, worse than in others—Louisiana, for example—creating a more equitable system of health care service will help, though that may be a challenge in the current infrastructure of healthcare and federal spending.

This means we need more testing to increase the prevention and early detection of HIV. The work being done in some FQHCs and private providers around the country helps, but there's still a long way to go when it comes to making testing accessible and easy for everyone.

"Thank god [FQHCs] are passionate about this, but you have to get the places involved that don't do HIV screening," Brennan said.

Until that happens, the distance between the U.S. and 90-90-90 might as well be a never-ending loop.