Zeena Nackerdien is a scientist and medical writer who previously performed research at institutions such as the National Institutes of Standards and Technology, Memorial Sloan Kettering Cancer, and Rockefeller University. Zeena has contributed this work independently of her current writing assistance to researchers at Montefiore Medical Center and has no conflicts of interest to declare.

Zeena Nackerdien, PhD

What if a 32-year-old man, previously in prime health, suddenly developed a persistent high fever unresponsive to antibiotics? With no cough or abdominal symptoms, his condition worsens, baffling his medical team. They notice purple lesions on his palate. Despite treatment, the man succumbs to Kaposi’s sarcoma due to HIV/AIDS.

Today, this hypothetical case is rare in the US because combination antiretroviral treatment (ART) has transformed HIV/AIDS from a near-ubiquitous death sentence to a chronic disease.Indeed, the estimated 12% decline in new HIV infections (2018 to 2022) and the fact that only an estimated 31,800 new HIV infections were detected in 2022 are positive reminders that a public-private sector partnership has brought the US within sight of ending the HIV epidemic (EHE).

However, 13% of people living with HIV (PLWH) do not know their status, and among people at high risk of acquiring the virus, preexposure prophylaxis (PrEP) for continuous protection is very low.

 In the absence of a significant scale-up in connecting high-risk individuals to accessible, affordable PrEP, the US risks failing to reach the goal of a 90% decrease in new HIV infections by 2030—1 of the primary goals of the EHE initiative.

 Thus, we risk a scenario of disease progression, analogous to the hypothetical case, and thousands of Americans being added to the global HIV-related death toll of more than 42 million at the time of writing.

: Key Long-Acting Agent Clinical Trials for HIV Preexposure Prophylaxis

The US sees higher HIV rates among gay and bisexual men, transgender women, Black/African American and Latin individuals, and people who inject drugs (PWID).

 The southern US, which comprises just over a third of the population, accounts for nearly half (49%) of new HIV infections.

 While new HIV diagnoses have dropped nationwide, the Deep South (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas) still faces a significant challenge. Their diagnosis rate is 65% higher than that of other Southern states (Arkansas, Delaware, Washington DC, Kentucky, Maryland, Oklahoma, Virginia, and West Virginia), which matches the US average of 17 per 100,000 people.

PrEP, a preventive antiretroviral treatment (ART) strategy, coverage is low among African American men who have sex with men (MSM) in the South, affected by stigma, healthcare mistrust, poverty, and misinformation. Additionally, clinic access is scarce in high-poverty areas, and awareness is also low among low-income African American women.

 While these challenges have to be addressed, it is also important to note that HIV is not regional and that less than 70% of all PLWH were virologically suppressed in 2022, and only 30% of PrEP-eligible individuals received these medications.

 Thus, a substantial proportion of the HIV-positive population still has detectable virus in their blood, which can lead to ongoing transmission and potential health complications.

Condom usage has contributed to HIV reduction, but not eradication, and is not feasible for those wishing to become pregnant.

 That is why the US Preventive Services Task Force (USPSTF) strongly recommends PrEP (alongside safe sex practices and continuous HIV care) for HIV prevention, meaning they are very confident it is highly beneficial when taken as prescribed. Health care professionals should offer PrEP to all sexually active adults and adolescents who are at risk of HIV.

PrEP can prevent HIV infection, reducing the risk by up to 99% from sex and at least 74% from injection drug use. It is recommended for all sexually active adults and adolescents at risk, weighing at least 35 kg (77 lb). Providers should discuss PrEP with all sexually active patients to increase awareness and reduce stigma, and it can be prescribed to any patient who asks for it, regardless of reported HIV risk factors. Any licensed provider can prescribe PrEP, which includes daily oral medications (Emtricitabine/tenofovir disoproxil fumarate [F/TDF], Emtricitabine/tenofovir alafenamide [F/TAF]), and the injectable long-acting cabotegravir (CAB) injected every 2 months for eligible patients (

Postexposure prophylaxis (PEP) involves a 28-day regimen of ART to prevent HIV infection after high-risk exposure and must be started as soon as possible.

 Both strategies are crucial in preventing HIV, but PrEP is a continuous preventive measure, while PEP is an emergency response.

While clinical trial differences in effectiveness have been observed among the different PrEP agents, real-world data suggest that this should not be the primary consideration in practice, as all the medications are highly, but not quite 100% effective. Instead, patient preference, safety, convenience, and cost should be considered.

 Due to biological, social, and cultural factors, women’s uptake of, adherence to, and persistence in the use of PrEP remains limited across the globe. This has led to calls for additional PrEP options.

Experts suggest considering CAB-LA for adults and adolescents of all genders at risk for HIV through sexual routes who cannot tolerate an oral regimen or prefer an injection. Additionally, CAB-LA is not known to affect renal function, making it a safer option for patients with renal issues.

 This does not negate the need for continued vigilance regarding drug toxicity and resistance.

 However, the convenience of dosing every 2 months with CAB-LA versus daily oral medications may still be challenging for some patients. CAB-LA and F/TAF are also more expensive than F/TDF and may require preauthorization, posing a barrier to care for some patients.

Cost remains a barrier for PrEP, with out-of-pocket expenses exceeding $1,000 per year for insured users. Even with available financial assistance, lack of insurance still hinders accessibility.

 Pending future Supreme Court decisions, help for HIV prevention and treatment can still be found through the Ryan White HIV/AIDS Program (RWHAP) Medical Provider tool, state HIV/AIDS toll-free phone numbers, and the Common Patient Assistance Program Application for low-cost medicines. RWHAP provides a range of core medical and support services, including case management, drug assistance, mental health services, and housing support for eligible individuals diagnosed with HIV or AIDS.

A syndemic refers to the occurrence of two or more health conditions that cluster within a population and exacerbate each other's effects. Syndemic theory examines how diseases and social problems interact and worsen each other, helping us find better ways to prevent and treat them together.

 Consistent with this theory, a recent study examined how gender-based violence (GBV) and post-traumatic stress disorder (PTSD) symptoms affected PrEP use among transgender and nonbinary (TGNB) individuals. It found that GBV predicted failure to start PrEP and PTSD symptoms were linked to stopping PrEP.

Conversely, a2018-2021 study in New York City found that integrating PrEP services with sexually transmitted infections (STIs) and other health care services in primary care and women's health clinics substantially increased the percentage of health care professionals prescribing PrEP, from 11.5% to 49%.

Similarly, an inpatient Addiction Consult Service (ACS) significantly increased PrEP/PEP prescriptions for people who inject drugs (PWID) by leveraging the reachable moment of hospitalization.

Community engagement programs that empower PWID have shown promise in expanding PrEP access. Engaging community leadership helps address structural barriers and ensures that services are tailored to the needs of high-risk individuals.

 Other innovative approaches have involved crowdsourcing solutions to enhance PrEP access, such as promotional campaigns tailored to community needs.

Consistently taking ART, as prescribed, can prevent or control HIV, enabling infected patients and their uninfected partners to have near-normal lifespans. However, ART usage must be combined with other factors, eg, safe sexual behaviors, giving PWID access to sterile needles, promoting safe sexual behaviors, supporting routine HIV testing, giving injecting drug users access to sterile needles, and reducing mother-to-child transmission through interventions during pregnancy, childbirth, and lactation. Even when these goals are met, ART carries a lifelong risk of medication resistance, side effects, and increased risk for chronic diseases versus HIV-free individuals. Additionally, access to ART is still restricted in many regions due to infrastructure, stigma, and cost. Instead of requiring lifelong ART, promising long-acting agents used alone or combined with other treatments seek to achieve prolonged viral remission or elimination.

In December 2021, the US FDA approved CAB-LA. Clinical trials showed CAB-LA to be safe and effective at preventing HIV. Given every 2 months, it offers a discreet, long-lasting option preferred by many at risk of HIV, and a formulation with a 4-month dosing interval is also currently under investigation (

 Analysis indicated that generic manufacturers could produce CAB-LA affordably.

 Another investigational long-acting agent, lenacapavir, showed remarkable efficacy in 2 separate phase 3 trials. Compared to traditional daily oral PrEP, lenacapavir achieved 100% prevention in cisgender women and a 96% HIV prevention rate in cisgender men who have sex with men, transgender men, transgender women, and gender nonbinary individuals.

Vaginal rings with tenofovir or dapivirine, lasting over 3 months and possibly including birth control, are in early development. A 1-month dapivirine ring has not been FDA-approved despite WHO's recommendation. Long-acting antibodies given by IV or injection are being developed for HIV prevention, and another preventive agent, MK-8527, is in development as a monthly pill.

Long-acting HIV PrEP can significantly enhance prevention efforts by addressing some of the challenges associated with daily ART. These agents, such as lenacapavir and cabotegravir, can reduce the need for frequent dosing and clinic visits, improving adherence and minimizing stigma. By offering extended protection with fewer side effects and lower risk of resistance compared to approved oral PrEP, long-acting PrEP can make HIV prevention more accessible and sustainable, especially in high-risk populations where logistical issues and stigma are prevalent.

Fast Facts: HIV in the United States. CDC April 22, 2024. Accessed January 13, 2025. 

https://www.cdc.gov/hiv/data-research/facts-stats/index.html

About ending the HIV epidemic in the US (EHE). CDC. March 20, 2024. Accessed January 13, 2025. 

https://www.cdc.gov/ehe/php/about/index.html

AIDSVu releases new data showing significant inequities in PrEP use among Black and Hispanic Americans. July 29, 2022. Accessed January 13, 2025. https://aidsvu.org/news-updates/prep-use-race-ethnicity-launch-22/

World Health Organization. The Global Health Observatory. Data on the size of the HIV/AIDS epidemic. Accessed January 13, 2025. 

https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/data-on-the-size-of-the-hiv-aids-epidemic

HIV.gov. Who is at risk for HIV? Updated June 15, 2022. Accessed January 14, 2025. 

https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/who-is-at-risk-for-hiv

Reif SS, Whetten K, Wilson ER, et al. HIV/AIDS in the Southern USA: a disproportionate epidemic. 

. 2014;26(3):351-359. doi:10.1080/09540121.2013.824535

Watson M, Johnson SD, Zhang T, Oster AM. Characteristics of and trends in HIV diagnoses in the Deep South Region of the United States, 2012-2017. 

. 2019;23(Suppl 3):224-232. doi:10.1007/s10461-019-02659-6

Traylor DO, Enriquez M, Thompson-Robinson M, Yu M, Bloom T, Bullock L. Barriers and facilitators that influence HIV pre-exposure prophylaxis (PrEP)-prescribing behaviors among primary care providers in the Southern United States. 

. 2024;16(8):e66868. Aug 14. doi:10.7759/cureus.66868

Hatlen TJ, Bender Ignacio R, Daar ES. Advances in treatment and prevention of HIV. 

. December 1, 2024. doi:10.1001/jama.2024.24027

Stover J, Teng Y. The impact of condom use on the HIV epidemic [version 2; peer review: 2 approved]. 

. 2022;5:91. doi:10.12688/gatesopenres.13278.2

U.S. Preventive Services Task Force. Task force issues final recommendation statement on PrEP for HIV prevention. Updated August 2023. Accessed January 15, 2025. 

https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/hivprep-bulletin.pdf

Clinician's Quick Guide: What is HIV PrEP. CDC. Updated April 22, 2024. Accessed January 15, 2025. 

https://www.cdc.gov/hivnexus/media/pdfs/2024/04/cdc-lsht-prevention-brochure-clinicians-quick-guide-what-is-hiv-prep.pdf

HIV Nexus: CDC resources for clinicians. Clinical guidance for PrEP. CDC. Updated August 20, 2024. Accessed January 17, 2025. 

https://www.cdc.gov/hivnexus/hcp/prep/index.html

Heck J, Höner Zu Siederdissen C, Krause O, et al. Concordance of emergency department physicians' decisions on HIV post-exposure prophylaxis with national guidelines: results from a retrospective cohort study. 

. 2024;16(2):219-226. doi:10.1093/inthealth/ihad076

Baker J, Rolls J. An update on expanding HIV preexposure prophylaxis. 

. 2023;36(2):17-24. doi:10.1097/01.JAA.0000911184.87186.0f

Mahomed S. Broadly neutralizing antibodies for HIV prevention: a comprehensive review and future perspectives. 

Menéndez-Arias L, Delgado R. Update and latest advances in antiretroviral therapy. 

. 2022;43(1):16-29. doi:10.1016/j.tips.2021.10.004

Kay ES, Pinto RM. Is Insurance a barrier to HIV preexposure prophylaxis? Clarifying the Issue. 

. 2020;110(1):61-64. doi:10.2105/AJPH.2019.305389

Health Resources & Services Administration. Ryan White HIV/AIDS Program (HRSA). Available care and services. Last reviewed December 2024. Accessed January 15, 2025. 

https://ryanwhite.hrsa.gov/hiv-care/services

Sneed T, Luhby T. Supreme Court to review Obamacare’s no-cost coverage of cancer screenings, heart statins and HIV drugs. 

. Updated January 10, 2025. Accessed January 15, 2025. 

https://www.cnn.com/2025/01/10/politics/obamacare-supreme-court-hiv-prep-cancer-screening-heart-statin/index.html

Rudd KE, Mair CF, Angus DC. Applying syndemic theory to acute illness. 

. 2022;327(1):33-34. doi:10.1001/jama.2021.22583

Storholm ED, Huang W, Ogunbajo A, et al. Gender-based violence and post-traumatic stress disorder symptoms predict HIV PrEP uptake and persistence failure among transgender and non-binary persons participating in a PrEP demonstration project in Southern California. 

Casey E, Kaplan-Lewis E, Gala K, Lakew R. Successful integration of HIV PrEP in primary care and women's health clinical practice: a model for implementation. 

. 2023;15(6):1365. June 13, 2023. doi:10.3390/v15061365

Rozansky H, Christine PJ, Younkin M, et al. Addiction consult service involvement in PrEP and PEP delivery for patients who inject drugs admitted to an urban essential hospital. 

. 2022;17(1):33-34. doi:10.1186/s13722-021-00255-8

Nishimoto L, Olisa AL, Imohi P, et al. Achieving HIV epidemic control through accelerating efforts to expand access to pre-exposure prophylaxis for people who inject drugs. 

Tieosapjaroen W, Ongkeko Jr AM, Yin Z, et al. Crowdsourcing strategies to improve access to HIV pre-exposure prophylaxis (PrEP) in Australia, the Philippines, and China. 

Alum EU, Uti DE, Ugwu OP, Alum BN. Toward a cure - Advancing HIV/AIDs treatment modalities beyond antiretroviral therapy: A Review. 

. 2024;103(27):e38768. doi:10.1097/MD.0000000000038768

Bekker LG, Das M, Abdool Karim Q, et al. Twice-Yearly Lenacapavir or Daily F/TAF for HIV prevention in cisgender women. 

. 2024;391(13):1179-1192. doi:10.1056/NEJMoa2407001

Delany-Moretlwe S, Hughes JP, Bock P, et al. Cabotegravir for the prevention of HIV-1 in women: results from HPTN 084, a phase 3, randomised clinical trial [published correction appears in 

. 2022 May 7;399(10337):1778. doi: 10.1016/S0140-6736(22)00783-8].

Han Y, Smith K, Johnson M, et al. Ultra-long-acting cabotegravir for HIV prevention: Phase I clinical trial findings. Presented at: Conference on Retroviruses and Opportunistic Infections (CROI); March 4, 2024; Denver, CO

Kelley CF, Acevedo-Quiñones M, Agwu AL, et al. Twice-Yearly Lenacapavir for HIV prevention in men and gender-diverse persons. 

. Published online November 27, 2024. doi:10.1056/NEJMoa2411858

Landovitz RJ, Donnell D, Clement ME, et al. Cabotegravir for HIV prevention in cisgender men and transgender women. 

. 2021;385(7):595-608. doi:10.1056/NEJMoa2101016

Jenkins SY, Resar D, Panos Z, et al. Securing accelerated access to long-acting injectable cabotegravir for HIV prevention in low- and middle-income countries. 

. 2023;26 Suppl 2(Suppl 2):e26101. doi:10.1002/jia2.26101

Gandhi RT, Landovitz RJ, Sax PE, et al. Antiretroviral drugs for treatment and prevention of HIV in adults: 2024 recommendations of the International Antiviral Society–USA Panel. 

. December 1, 2024. doi:10.1001/jama.2024.24543

Articles

Despite medical advances, HIV prevention faces roadblocks—low PrEP adoption, stigma, and accessibility issues threaten progress. Experts push for innovative, long-acting solutions to end the epidemic.

Breaking Barriers: The Future of HIV Prevention and the Fight for Widespread PrEP Access

Bacterial pneumonia, medical concept. 3D illustration showing rod-shaped bacteria inside alveoli of the lung.

Health care–associated infections (HAIs) are regarded as threats to patient safety, and select HAIs are used as metrics by US stakeholders to evaluate care quality.

 Hospital-acquired pneumonia (HAP), whether ventilator-
associated (VAP) or not (NVHAP), is a common lung infection posing substantial challenges.

 It is linked to extended hospital stays, intensive care unit (ICU) requirements, antibiotic usage, occurrence of sepsis, morbidity, readmission rates within 30 days, elevated health care costs, and mortality. 

Findings from a recent case-control study of Medicare beneficiaries showed prolonged hospital stays and costs in the HAP group as well as a likelihood of death 2.8 times greater than that of the control group.

 Although intubated patients on mechanical ventilation have a higher risk of developing pneumonia, the mortality rates for patients with VAP and those with NVHAP are similar.

 However, most institutions focus on VAP, not NVHAP, due to difficulty defining and tracking the latter condition and limited understanding of its burden and preventability.

Thus, severe pneumonia can be deadly, and survivors may experience short- and long-term pulmonary and extrapulmonary complications. Despite guideline recommendations calling for timely and appropriate antimicrobial treatment, the goal is not being met in managing HAP. Inappropriate use of antibiotics contributes to the development of multidrug-resistant pathogens, and patients with HAP experience high readmission rates within 30 days.

As the US population ages, preexisting conditions that increase the risk of HAP, such as lung disease and multiple organ system disorders, are likely to become more prevalent.

 US modeling data from 2010 to 2019 revealed that HAP can serve as a proxy for safety events during the index admission. This finding implies that reducing hospital-acquired adverse events, including HAP, may result in fewer unplanned readmissions.

 Therefore, in addition to optimizing HAP treatment with multifaceted interventions, focusing on prevention through improved care—leading to shorter hospital stays—becomes a critical strategy.

Ventilator-associated pneumonia (VAP) or not ventilator-associated Pneumonia (NVHAP).

According to the American Dental Association, “Beyond teeth and gums, the mouth serves as a window to the rest of the body and can show signs of infection, nutritional deficiencies, and systemic diseases.”

 The mouth is a complex ecosystem featuring hard (teeth) and mucus-covered (tongue, lips, cheeks, palate) regions. It is continuously moistened by saliva and, in some areas, gingival fluid, which also provides nutrients to resident microorganisms. 

More than 700 bacterial species coexisting with fungi, viruses, archaea, and protozoa form the oral microbiome. The composition of this consortium is influenced by factors such as age, dietary habits, alcohol, tabagism, social status, medications (eg, antibiotics), toxic substances, pregnancy, and hereditary predisposition.

Oral microbiota significantly affect lung microbiota due to anatomical proximity, meaning oral health is closely connected to lung health.13 A systematic review established a consistent association between poor oral health—such as caries and periodontitis—and pneumonia.

Microbial profile shifts due to poor oral hygiene can occur in all patients with HAP, especially those with dentures. The denture-associated microbiome harbors an abundance of respiratory pathogens potentially protected by oral biofilms against antimicrobial therapy.16

Additionally, it is well-known that the dental plaque in patients with VAP is colonized with 

, and these pathogens decrease following extubation.

 Findings from other studies linking poor oral health and pneumonia development highlight the need for rigorous oral care.

Notably, aspiration of oropharyngeal secretions containing respiratory pathogens is considered critical in pneumonia development and portends a dismal prognosis.

 Decreased host immunity, reduced pulmonary flow, oral hygiene, level of alertness, salivary production and flow, and difficulty swallowing can all contribute to aspiration risk.


Compared with patients who can swallow, patients who experience acute stroke with dysphagia are almost 10 times more likely to develop pneumonia.

 However, stroke is not the only cause of dysphagia. Decreased consciousness, delirium, gastroesophageal reflux disease, and mechanical obstruction (eg, esophageal cancer, scarring) are among the other causes. Although there are promising findings from studies suggesting that dysphagia screening can reduce HAP incidence, tools used for this purpose have not been independently validated.

Patients who are intubated and on mechanical ventilation for more than 48 hours and then develop pneumonia are diagnosed with VAP, a severe lung infection representing up to 32% of all HAIs and up to 10% of all pediatric device–related infections. Factors contributing to VAP include microbial colonization of the oropharynx or stomach, conditions promoting gastric reflux and aspiration (such as depressed mental status, prone position, and nasogastric tubes), extended intubation, and impediments to pulmonary hygiene (such as thoracic or abdominal surgery and immobilization).

Critical care team members aim to prevent VAP with sets of quality indicators or scientifically proven combined interventions known as bundles. Cuff pressure control, subglottic suctioning, peptic ulcer disease and deep vein thrombosis prophylaxis, semirecumbent positioning, and hand and oral hygiene were the most common components of VAP bundles (

 Results from a systematic review and meta-analysis of different VAP bundles implemented across a variety of ICU settings showed that care bundles without selective oropharyngeal decontamination (SOD) were associated with a 42% reduction in VAP rates. In contrast, the inclusion of SOD in the VAP bundle was associated with a further drop of 70% in VAP rates.

 Because there are conflicting data regarding the use of chlorhexidine gluconate—a cationic antiseptic with broad-spectrum activity against bacteria, fungi, and enveloped viruses—there has been a lack of clarity regarding the adoption of this particular approach to prevent VAP.

 However, a systematic review and meta-analysis of 15 eligible HAP studies (10,742 patients), which included VAP (2033 in the ICU), confirmed that toothbrushing is effective in VAP prevention and should be considered in relevant care bundles.

Reducing VAP cases is crucial, but not all cases are preventable. For instance, ICUs with high numbers of patients with neurosurgical conditions/trauma or homeless individuals with oral health issues will likely not achieve VAP rates of 0%. Maybe the question should be whether institutions serving such high-risk populations could still manage highly effective preventive bundle implementation rates. According to findings from a European study using surveillance data from more than 78,000 participants in 525 ICUs, the answer is yes. Data adjusted for case mixes showed that hospitals with the highest infection rates could prevent more than 50% of their VAP rates, similar to data reported by other institutions.

NVHAP is a severe lung infection affecting hospitalized patients. It leads to increased antibiotic use, frequent ICU admissions, and a 20% readmission rate for survivors.

 Thus, it is now included in a guideline from The Society of Healthcare Epidemiology of America.

 Addressing NVHAP is crucial, and preventive measures—such as oral care, dysphagia management, and respiratory therapy—can significantly reduce cases.

Public health strategies such as those used for COVID-19 may also play a preventive role.

Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to provide oral care) also showed that standardized oral care provided to military veterans in participating health care facilities could decrease pneumonia rates by up to 60%. In 2016, the reduction in NVHAP was estimated to save more than $100,000 in 12-month direct health care costs.

 Similarly, a single-institution pilot oral care program implemented in 2016 by the Salem VA Medical Center in Salem, Virginia, decreased NVHAP rates by 92%, leading to 13 deaths prevented over 19 months and an estimated cost savings of $2.84 million.

Continued education of nursing staff has also been shown to correlate with reduced costs and duration of hospitalization associated with HAP.

 Results from a separate study also showed that a nurse-driven oral care protocol improved pneumonia outcomes for all adult hospital patients, reducing costs, length of stay, and mortality.

 There is also the need for interprofessional collaboration in implementing nurse skills bundles to reduce HAP risk.

 This would first involve monitoring head-of-bed elevation, oral hygiene, patient mobility, coughing, and deep breathing to reduce HAP risk.

With the aid of in-house research, nurses may implement oral care using a soft bristle/electric suction toothbrush and toothpaste containing sodium
bicarbonate, use a mouthwash without alcohol to complete oral care, and ensure that dentures are cleaned after each meal and before bedtime. If there are risk factors for aspiration, a nurse may initiate a consultation with a speech therapist, for example, to ascertain a patient’s ability to swallow. Polypharmacy should be discussed with physicians and pharmacists in case some medications could contribute to aspiration risks. Pain relief and nutritional support should also be addressed as appropriate.

The evidence presented in this article does not imply that a combination of consensus-based VAP/NVHAP definitions, interprofessional teams, and preventive care bundles incorporating oral care will drop HAP rates to 0%. This would imply that all forms of HAP are preventable. Instead, it suggests that substantial HAP reductions are realistic. In a world where common antibiotics against superbugs are failing and vaccine refusals are on the rise, implementing HAP preventive care bundles incorporating oral care, where possible, will assume added importance to mitigate often deadly infections.

1. Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in U.S. hospitals. 

. 2018;379(18):1732-1744. doi:10.1056/NEJMoa1801550

2. Shorr AF, Zilberberg MD. Admitting what we do not know about pneumonia readmissions. 

. 2015;148(1):4-6. doi:10.1378/chest.14-2987

3. Wolfensberger A, Clack L, von Felten S, et al. Implementation and evaluation of a care bundle for prevention of non-ventilator-associated hospital-acquired pneumonia (nvHAP) - a mixed-methods study protocol for a hybrid type 2 effectiveness-implementation trial. 

. 2020;20(1):603. doi:10.1186/s12879-020-05271-5

4. Baker DL, Giuliano KK, Desmarais M, Worzala C, Cloke A, Zawistowich L. Impact of hospital-acquired pneumonia on the Medicare program. 

. 2024;45(3):316-321. doi:10.1017/ice.2023.221

5. Ehrenzeller S, Klompas M. Association between daily toothbrushing and hospital-acquired pneumonia: a systematic review and meta-analysis. 

. 2024;184(2):131-142. doi:10.1001/jamainternmed.2023.6638

6.Jones BE, Sarvet AL, Ying J, et al. Incidence and outcomes of non-ventilator-associated hospital-acquired pneumonia in 284 US hospitals using electronic surveillance criteria. 

. 2023;6(5):e2314185. doi:10.1001/jamanetworkopen.2023.14185

7. Cillóniz C, Torres A, Niederman MS. Management of pneumonia in critically ill patients. 

. 2021;375:e065871. doi:10.1136/bmj-2021-065871

8. Sano M, Shindo Y, Takahashi K, et al. Risk factors for antibiotic resistance in hospital-acquired and ventilator-associated pneumonia. 

. 2022;28(6):745-752. doi:10.1016/j.jiac.2022.02.012

9. Wang Y, Eldridge N, Metersky ML, et al. Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. 

. 2022;5(5):e2214586. doi:10.1001/jamanetworkopen.2022.14586

10. Kim BG, Kang M, Lim J, et al. Comprehensive risk assessment for hospital-acquired pneumonia: sociodemographic, clinical, and hospital environmental factors associated with the incidence of hospital-acquired pneumonia. 

. 2022;22(1):21. doi:10.1186/s12890-021-01816-9

11. Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. 

12. Prioritize oral health care in America. News release. American Dental Association. May 23, 2024. Accessed May 31, 2024. https://www.ada.org/about/press-releases/oral-health-legislation-on-capitol-hill

13. Santacroce L, Passarelli PC, Azzolino D, et al. Oral microbiota in human health and disease: a perspective. 

. 2023;248(15):1288-1301. doi:10.1177/15353702231187645

14. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. 

. 2006;77(9):1465-1482. doi:10.1902/jop.2006.060010

15. Gaeckle NT, Pragman AA, Pendleton KM, Baldomero AK, Criner GJ. The oral-lung axis: the impact of oral health on lung health. 

. 2020;65(8):1211-1220. doi:10.4187/respcare.07332

16. Twigg JA, Smith A, Haury C, et al. Metataxonomic sequencing reveals compositional shifts within the denture-associated microbiome in pneumonia. 

. Preprint posted online February 10, 2020. doi:10.21203/rs.2.23022/v1

17. Sands KM, Wilson MJ, Lewis MAO, et al. Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation. 

. 2017;37:30-37. doi:10.1016/j.jcrc.2016.07.019

18. Eltringham SA, Kilner K, Gee M, et al. Factors associated with risk of stroke-associated pneumonia in patients with dysphagia: a systematic review. 

. 2020;35(5):735-744. doi:10.1007/s00455-019-10061-6

19. Chang MC, Choo YJ, Seo KC, Yang S. The relationship between dysphagia and pneumonia in acute stroke patients: a systematic review and meta-analysis. 

. 2022;13:834240. doi:10.3389/fneur.2022.834240

20. Livesey A, Quarton S, Pittaway H, et al. Practices to prevent non-ventilator hospital acquired pneumonia: a narrative review. 

. Published online April 23, 2024. Accessed July 21, 2024. doi:10.1016/j.jhin.2024.03.019

21. Kohbodi GA, Rajasurya V, Noor A. Ventilator-associated pneumonia. 

. StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK507711/

22. Mastrogianni M, Katsoulas T, Galanis P, Korompeli A, Myrianthefs P. The impact of care bundles on ventilator-associated pneumonia (VAP) prevention in adult ICUs: a systematic review. 

. 2023;12(2):227. doi:10.3390/antibiotics12020227

23. Quick safety issue 61: preventing non-ventilator hospital-acquired pneumonia. The Joint Commission. September 13, 2021. Accessed June 2, 2024. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-61/

24. .Keyt H, Faverio P, Restrepo MI. Prevention of ventilator-associated pneumonia in the intensive care unit: a review of the clinically relevant recent advancements. 

25. Landelle C, Nocquet Boyer V, Abbas M, et al. Impact of a multifaceted prevention program on ventilator-associated pneumonia including selective oropharyngeal decontamination. 

. 2018;44(11):1777-1786. doi:10.1007/s00134-018-5227-4

26. Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. 

. 2011;11(11):845-854. doi:10.1016/S1473-3099(11)70127-X

27. Price R, MacLennan G, Glen J; SuDDICU Collaboration. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. 

28. Lambert ML, Silversmit G, Savey A, et al. Preventable proportion of severe infections acquired in intensive care units: case-mix adjusted estimations from patient-based surveillance data. 

29. Kallet RH. The vexing problem of ventilator-associated pneumonia: observations on pathophysiology, public policy, and clinical science. 

. 2015;60(10):1495-1508. doi:10.4187/respcare.03774

30. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. 

31. .Klompas M. Hospital-acquired pneumonia in nonventilated patients: the next frontier. 

. 2016;37(7):825-826. doi:10.1017/ice.2016.101

Hospital-acquired pneumonia (HAP), including ventilator-associated (VAP) and non-ventilator (NVHAP) forms, poses significant health risks, contributing to mortality, readmission, and high costs.

Zeena Nackerdien, PhD

Articles

Breaking Barriers: The Future of HIV Prevention and the Fight for Widespread PrEP Access

Oral Wellness Measures Show Mitigation in Hospital-Acquired Pneumonia

CLABSI Prevention in the Post-COVID-19 Era