HIV Prevention in the 21st Century


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Reaching the goals of the National HIV/AIDS Strategy. This presentation was originally conducted at the Office of HIV Planning's Community Empowerment Workshop held at St. Luke's Church on October 16, 2012.

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  • What are the conventional HIV prevention methods? What did we promote the first 25 years?
  • Let’s remind ourselves of the goals of the National HIV Strategy. What do you think are the best ways to meet these goals?
  • Here are just some of the tools in our HIV prevention tool box. All of these are a part of the local strategy to end AIDS. We have two videos to watch that will help us understand two of the more recent strategies. But first let’s talk about what we know about each one:Structural interventions - what are they?Test and Treat – what does this mean? How is it applied locally?Targeted and routine HIV testing – Who are we targeting? How do we target testing? What does a routine test mean?Behavioral interventions for high risk individuals – who is at high risk? What types of interventions/PrEP and PEP – what are these? Who are the eligible recepients?Prevention with Positives – what does this really mean? What types of interventions are used? Does this tigmatize HIV+ people?Syringe exchange and harm reduction – not currently funded b federal $ but provided locally. One of the most effective HIV preventi on interventions. Why the controversy?
  • We still have a lot of work to do for the HIV vaccine,microbicides and a Cure.What do we know about progress on a vaccine? Human trials are starting on a promising vaccine. We have had limited success with prevention vaccines – still a lot of research going on.Microbicides Primarily for women to control their risk Studies are ongoing about the use of gels, rings and other methods. We have a short video about progress on them.A cure Very little money is invested in research for a cure, but that has changed a little. Science changes all the time.
  • Locally we are targeting MSM, and YMSM – particularly men of color.Our HIV epidemic is primarily male and primarily African American. Youth numbers are rising at alarming rates, particularly for MSM.Why do you think the CDC wants HIV prevention to be targeted to the groups with the most infections? Do you think this is an effective way to go about ending the epidemic? Do you see flaws in this way of thinking?CDC targets certain groups- particularly with testing and behavioral interventions because it is most cost-effective to do so. You are more likely to afvert an infection or identify an infection if you target activities to the groups with the most prevalence (number of infections).
  • Let’s walk through all the tool sin the prevention toolbox. Which do you think are the most effective? What do you think we should do more of?
  • 1.1 million in the US with HIV/AIDS21% of those not aware HIV+ (US)35%-45% of newly diagnosed individuals have AIDS within 1 year (US)Longer delays in linkage with medical care are associated with greater likelihood of progression to AIDS by CD4 criteriaHIV+ people not linked to care pose a greater risk of transmissionGardner concludes that ~75% of newly diagnosed HIV+ people successfully like to HIV care within 6-12 months, 80-90% link within 3-5 years3 population based studies in US found 45-55% of known HIV+ individuals fail to receive HIV care during any yearIn some communities, one-third of HIV+ people fail to access care for 3 consecutive years~50% of HIV+ (aware) people are not engaged in regular HIV care.Poor engagement in care is associated with poor health outcomes, including increased mortality and increased risk of HIV transmissionGardner estimates that 80% of in-care HIV+ individuals should be receiving ART, but 25% of those are not.4-6% of in-care HIV+ people discontinue ART each year70-80% adherence leads to durable viral suppression in most people78-87% of individuals on ART had an undetectable viral load.Epidemiological data suggests that ART reduces risk of HIV transmission in serodiscordant heterosexual couples by 92-98%Ecological data show that incidence of HIV transmission may be occurring in communities with high treatment coverage (San Francisco)A meta analysis examined 11 cohorts of serodiscordant heterosexual couples with the HIV+ partner on ART and a VL<400 showed NO transmissions (Attia, Egger, Muller, et al., 2009)HPTN 052 – HIV+ men and women who were on ART had a 96% reduced risk of transmitting the virus to sexual partnersMugavero, Amico, Westfall et al., 2012Higher rates of early retention in HIV care are associated with achieving viral load suppression and lower cumulative viral load burden63% of overall sample achieved viral load suppression in less than a year after entry into careInsured people reached suppression fasterThe more visits (less no shows) the more likely the person was to have viral load suppressionEach clinic “no show” conveyed a 17% increased risk of delayed viral load suppression
  • HIV-infected number is estimate based on CDC estimate that 21% of HIV infected people do not know status. Number calculated by adding 21% to 15,753 of known HIV+.HIV-diagnosed, #linked and retained in care are from AACO surveillance dataOn ART and suppressed viral load #’s are estimated from Medical Monitoring Project data
  • Let’s look at the continuum of care and how certain factors increase or decrease someone’s ability to engage and stay in care. The red items at the top are barriers to care and the green items are things that can help facilitate access. If you look in the middle you will see each step along the ‘test and treat’ strategy and where people can be lost or delayed.Do you think there is anything left off this model? What do you think are the biggest barriers to care? What can we do to prevent people from delaying entry to care? Keep them in care? We talked about your experiences and ideas this morning about these issues of linkage into care. Do you have anything additional after our conversation today?
  • PrEP is controversial and we are going to talk a little about why. We are still trying to figure out how and where PrEP is going to be provided locally.Biggest problem --- Who is going to pay for it???
  • This map is provided to give us prospective that the US is not alone in the fight. And all things considered we are doing far better than a lot of other places in the world. A lot of the advancement in HIV prevention globally is through the support and innovations in the US. What do you all think about this map? Is there anything new to you? Shocking?
  • Let’s review this mind map again and see if there are questions we still have or statements we want to make. Is there anything not on the list?Which would you prioritize? Why?
  • HIV Prevention in the 21st Century

    1. 1. HIV prevention in the 21st centuryReaching the goals of the National HIV/AIDS Strategy
    2. 2. Road Map to HIV Infection
    3. 3. HIV Prevention 1.0
    4. 4. National HIV AIDS Strategy Reduce HIV rate Coordinate d response Increase access to care for people Reduce HIV- living with HIV and related health improve their inequalities health outcomes
    5. 5. HIV Prevention 2.0 Structural Syringe Intervention exchange/harm s reduction • Condoms • HIV testing laws Prevention Test and with Treat Positives PrEP and Targeted and routine PEP HIV testing Behavioral interventions for High Risk Individuals
    6. 6. Still working on….. Vaccine Microbicides Cure
    7. 7. High Impact HIV Prevention
    8. 8. An Overview of HIV PreventionContent courtesy of Roget
    9. 9. Intro to ‘Test and Treat’ Most people in HIV treatment (ART) reach undetectable VL People with undetectable viral load are significantly less likely to transmit virus Collectively, individuals with lower VL lead to communities with lower community VL = less transmissions Failures in the system of care pose barriers to full success of T&T:  Late diagnosis  Non-linkage or flawed linkage to care  Insufficient use of ART  Non-adherence to ART
    10. 10. Test and Treat Components (HRSA) Testing and identification of PLWHA as soon as possible Linkage of people testing positive for HIV to HIV care Patient education to encourage self management and facilitate retention in care, adherence to treatment, and prevention of STIs Supportive services for promotion of sexual health maintenance Monitoring and evaluation of test and treat strategy
    11. 11. Overview of HIV ‘Test and Treat’Content courtesy of Roget
    12. 12. Philadelphia Estimate for Stage ofEngagement in Care25,000 19,69120,000 15,75315,000 11,50010,000 7,719 6,793 5,366 5,000 - HIV-infected HIV-diagnosed Linked to HIV Retained in On ART Supressed viral (as of care HIV care load (<=200 12/31/09) copies/mL)Source: AACO, Dr. Kathleen Brady
    13. 13. Overview of Continuum of CareContent courtesy of Roget
    14. 14. Overview of Pre-Exposure ProphylaxisContent courtesy of Roget
    15. 15. Innovations in Global Prevention
    16. 16. An Overview of HIV PreventionContent courtesy of Roget
    17. 17. Contact Nicole Johns Office of HIV Planning 340 N. 12th Street Suite 203 Philadelphia, PA 19107 215-574-6760 ext. 108 For more information on Roger Tatoud: