Wastewater Sampling: A New Tool to Accelerate Ending the HIV Epidemic

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PROJECT SUMMARY Current estimates are that 57% of persons in the U.S. with HIV are suppressed, leaving 43% unsuppressed, including about 13% who are undiagnosed and 30% who have been diagnosed but are not currently suppressed. Identifying persons with unsuppressed HIV to link them to care and antiretroviral treatment (ART) is critical for improving health and reducing new infections. New epidemiologic tools that identify in real time communities with high amounts of circulating HIV may enhance efforts to reduce HIV transmission and substantially contribute to ending the HIV epidemic. During the SARS-CoV-2 (SCV2) pandemic, we and others used “wastewater environmental virology” to monitor and respond to COVID. It uses viral capture and PCR detection of viral nucleic acid from wastewater collection sites to detect, quantify, and predict total SCV2 activity in time. We built a robust and mature wastewater sampling program for the Houston region that includes weekly assessment of 39 wastewater collection sites covering about 4 million residents. Our recent preliminary data demonstrate that HIV is detected in wastewater. Wastewater testing is unbiased, comprehensive, real-time, quantitative, and not influenced by access to health care, stigma or denial. We hypothesize that our pioneering wastewater sampling program can be applied as a powerful new tool to identify geographic areas with a high active burden of HIV, reflecting substantial numbers of people with undiagnosed or untreated HIV infection. Resources can then be mobilized to these communities to enhance HIV outreach, testing, prevention and linkage to care. The specifics aims are: 1) To develop a sensitive, reproducible, and streamlined wastewater HIV detection pipeline; 2) To develop epidemiologic models incorporating data from wastewater sampling as a novel and informative parameter along with routine surveillance data on HIV diagnoses and population data; 3) To characterize and incorporate stakeholder preferences, priorities, and recommendations for engaging key community stakeholders in the HIV wastewater sampling program with consideration to the ethical, legal, social, and cultural contexts of individuals living in target neighborhoods; 4) To determine if delivering proven public health interventions to neighborhoods as directed by wastewater data can reduce the wastewater viral load and increase HIV diagnoses in those neighborhoods. This research will enhance the Respond pillar of the End the HIV Epidemic (EHE) strategy. It will leverage and strengthen partnerships between the researchers and the Houston Health Department, the regional public health authority overseeing many EHE programs in Houston. The work in Houston, a high priority EHE region, will result in: (i) the US’s only HIV wastewater sampling program, (ii) epidemiologic models enhanced with wastewater data that identify unmet testing and treatment needs, (iii) community-informed and ethically appropriate, real-time public health monitoring that reduces the number of people with unsuppressed HIV, and (iv) tools and expertise that can be disseminated to other areas.