HIV PreventionCenters for Disease Control and Prevention
Burden of HIV in the United States 1.1 million people living with HIV Net increase of 40,000 people with HIV infections each year 56,000 new infections (2006) 16,000 deaths (2006) HIV infected people who start antiretroviral treatment (ART) are now expected to live at least an additional 35 years Lifetime treatment costs of ~$400,000
Number of people living with HIV continues to increase sharply HIV Incidence and Prevalence, United States, 1977–2006 1,200,000 New HIV Infections (Incidence) 1,000,000 People Living With HIV/AIDS (Prevalence) 800,000 600,000 400,000 200,000 0 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006JAMA 2008;300(5):520-529.Campsmith M, et al. CROI 2009.
Stark disparities in HIV/AIDS among different groups 95% of people with AIDS are MSM, African American, Latino, or IDU African Americans are 8 times more likely than whites to have HIV Latinos are 3 times more likely to have HIV than whites MSM are >40 times more likely to have HIV than other men and womenCDC, HIV Surveillance Report,2008. Published June 2010. www.cdc.gov/hiv/surveillance/resources/reportsMSM = Men having sex with menIDU = Intravenous drug users
From 2005-2008, the percentage of HIV diagnoses attributed to male-to-male sexual contact increased — 37 states and 5 U.S. dependent areasNote: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting.1Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.2 Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
In 2008, the majority of HIV diagnoses among males were attributed to male-to-male sexual contact; among females the majority were attributed to heterosexual contact — 37 states and 5 U.S. dependent areas Males N=31,595 4% 15% 72%Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting.a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
From 2005-2008, the percentage of HIV diagnoses increased among Blacks/African Americans – 37 states and 5 U.S. dependent areas ,%Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.a Hispanics/Latinos can be of any race.
HIV prevention works Saves lives and money Our collective prevention efforts have led to a dramatic reduction in HIV infections • Estimated number of new HIV infections per year was 130,000 in 1985 • Down to an estimated 56,000 new HIV infections per year in 2006 Conservative estimates are that prevention efforts have: • Averted more than 350,000 HIV infections in the United States • Saved more than $125 billion in medical costsSource: Holtgrave DR. Written testimony on HIV/AIDS incidence and prevention for the US House of Representatives Committee on Oversight and Government Reform. September 16, 2008.
Key HIV prevention strategiesPromote: Abstinence (or delaying sex) Fewer sexual partners (ideally, monogamous relationship with an uninfected partner) Consistent and correct use of condoms (male/female) Not sharing syringes for injection drug use
Cost benefits of HIV prevention Pennies ~$400,000Cost of condoms Lifetime cost of treating one HIV- infected person
Other HIV prevention strategies Antiretroviral drugs (ARVs): • To prevent perinatal transmission • To reduce infectiousness • To prevent new infections (as Pre-Exposure Prophylaxis [PrEP]) Male circumcision • To reduce risk of HIV infection through penile-vaginal sex
Pre-Exposure Prophylaxis (PrEP) Potential users: HIV-uninfected persons at high risk of becoming infected • High risk may include sexual partner who has HIV, multiple partners, frequent STDs, or other evidence of high risk • Recent trial demonstrates the safety and efficacy of PrEP for MSM at high risk Cost-effectiveness depends on: • HIV incidence in target groups • Cost of medication and services • Ability to maintain or increase existing risk reduction behavior • Adherence to medication • $34,000-$320,000 per QALY savedSource: Paltiel et al. CID 2009:48(6):806-816 Smith, et al. MMWR 2011:60(03);65-68
PrEP with daily tenofovir/emtracitabine can reduce HIV risk in MSM 44% reduction in acquisitionSource: Grant RM et al. (2010). NEJM; published online Nov. 23, 2010.
Policy, Systems, and Environmental Change Integrating Prevention and HealthcarePolicy development and support Guidelines and recommendations (testing, prevention with positives, ART) Quality measures: Development and uptake Reimbursement coding guidance
Policy, Systems, and Environmental Change Integrating Prevention and HealthcareNew programs and models Expanded Testing Initiative: 30 jurisdictions covering >90% of epidemic • Over 2.6 million HIV tests conducted; 27,000 HIV infections diagnosed Enhanced HIV Prevention Planning: 12 urban areas covering 44% of epidemic • Integrating HIV prevention, care, treatment services across health care system and community
Testing and diagnosis is prevention 21% (230,000) with undiagnosed HIV • Account for approximately 50% of new HIV transmissions 79% (870,000) with diagnosed HIV • More likely than undiagnosed to access prevention and treatmentSource: Marks G, et al (2006). AIDS 20(10): 1447-1450.
HIV testing is a prevention strategy CDC’s 2006 HIV Testing Recommendations for Health Care Settings • Promote routine screening of patients age 13-64 Routine, opt-out screening in clinical settings costs $2,000-$6,000 per HIV diagnosis confirmedSource: Campsmith M et al. (2010). JAIDS 53:619--24.
Key approaches and program considerations in HIV prevention HIV testing and linkage to care Prevention with positives Policy and structural interventions Targeted interventions Surveillance, monitoring, and evaluation Evidence-based planning Health equity Health reform Program collaboration and service integration
Focusing resources Burden of disease • Geographic distribution • Groups disproportionately affected by HIV (MSM, African Americans, Latinos, injection drug users) HIV prevention services • For people living with HIV • For people at high risk for HIV infection Monitoring the epidemic, sharing, and using information Discovering and operationalizing new interventions
Maximizing impact Target programs to people and geographic areas most at risk for transmission or acquisition Focus on interventions with evidence for large effect size Choose feasible efforts with potential for large-scale implementation
―The United States will become a place where new HIVinfections are rare and when they do occur, everyperson, regardless of age, gender, race/ethnicity, sexualorientation, gender identity or socio-economiccircumstance, will have unfettered access to highquality, life-extending care, free from stigma anddiscrimination.‖ —Vision of the National HIV/AIDS Strategy