HIV Prevention among Men Who Have Sex With Men         Greg Millett     CDC IAC Sympsoium        July 22, 2012
Scientific Advances: Biological Interventions (Cairns, 2012)
Global HIV prevalence of HIV in MSM              compared with regional adult prevalence in 2011Source: Beyrer, Baral, van...
Challenges
Greater HIV transmission efficiency among MSM         compared with heterosexuals• Greater background  prevalence in      ...
Sexual role versatility and protective effect of  circumcision among MSM vs. heterosexualsCircumcision Heterosexual Men   ...
Per-act-risk of transmission for UAI  among MSM (cART vs pre cART era)• In population with high  cART coverage (70%), per-...
Continued Potential for HIVTransmission among Virally Suppressed • Determine the prevalence of seminal HIV shedding   amon...
TasP not associated with reductions in  HIV incidence among MSM in UK                         • 40 000 HIV+ UK MSM        ...
Co-Occurring Conditions and  Amplification of HIV Risk among MSM“AIDS prevention amongMSM has overwhelmingly              ...
Mean Community Viral Load among White and Black MSM Living with HIV/AIDS in DC, 2008                                      ...
Disparities persist between black and whiteUndiagnosed HIV                       MSM throughout treatment cascadeOR, 6.38 ...
Undiagnosed HIVOR, 6.38 (4.33-9.39)    HIV             Diagnosed HIV+ Detection         OR, 3.00 (2.06-4.40)              ...
Criminalization of Homosexuality & HIV PrevalenceDisparities by Region                                                    ...
Funding Challenges: MSM not    targeted proportionate to HIV burden   International examples              National exmple•...
Global HIV prevalence among MSM, 2007-2011Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeye...
Opportunities
Zeroing on HIV effectiveprevention interventions
HIV Prevention Costs                  (Monetary and Otherwise)• Modeling cost of various                • MSM-GF survey of...
ART coverage and reductions in HIV incidence             among MSM in DenmarkBiomedical interventions reversing trends   •...
Combination prevention for MSM & attaining   the National HIV/AIDS Goals (Sorenson & Sansom, CROI, 2011)  Interventions   ...
Population attributable risk and cost  analyses in intervention planningInterventions targeting low prevalenceactivities a...
Evaluating Harm Reduction Activities                  among MSM•   Data from prospective studies of HIV-               •  ...
Risk reduction strategies are complex         and vary by context                      No sex or no                       ...
Thank YouGregorio A. MillettGMillett@CDC.gov
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Examples from HIV Prevention and Treatment: HIV Prevention among Men Who Have Sex with Men - Gregorio Millett

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  • 40x more likely to become infected than hets, but…
  • We know that there is some evidence that diagnosing most positives and getting them onto ART is associated with declines in HIV incidence. Consider the case of Denmark and the results reported during AIDS 2010 in Vienna.
  • CDC presented a mathematical model that examined various actions stipulated in the strategy singly and in combination. Each intervention by itself had a smaller effect. Combining each of the interventions produced robust effects to achieve each goal of the National HIV/AIDS Strategy.
  • Timeline of what men did, but also represents all of the behaviors that men engage in now. Diveristy of behaviors and we need to make sure that we have messages for emn who engage in each of these. Risk reduction varies by person, time, location– even within same person
  • Examples from HIV Prevention and Treatment: HIV Prevention among Men Who Have Sex with Men - Gregorio Millett

    1. 1. HIV Prevention among Men Who Have Sex With Men Greg Millett CDC IAC Sympsoium July 22, 2012
    2. 2. Scientific Advances: Biological Interventions (Cairns, 2012)
    3. 3. Global HIV prevalence of HIV in MSM compared with regional adult prevalence in 2011Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012
    4. 4. Challenges
    5. 5. Greater HIV transmission efficiency among MSM compared with heterosexuals• Greater background prevalence in “…even substantial behavior change, such concentrated epidemics in extra-primary as reductions• Greater likelihood of partnerships, would not reduce transmission frequency enough to control infection during epidemics of HIV among MSM.” anal sex – 18x greater (Beyrer, 2012) – Equal vaginal & anal per contact risk probabilities= 80% reduction in incidence• Transmission chain interruption W M, but Graphic from: E. White not M M
    6. 6. Sexual role versatility and protective effect of circumcision among MSM vs. heterosexualsCircumcision Heterosexual Men Circumcision MSM Weiss, AIDS, 2000 Millett, JAMA, 2008
    7. 7. Per-act-risk of transmission for UAI among MSM (cART vs pre cART era)• In population with high cART coverage (70%), per- act anal intercourse transmission probability estimates for URAI ‘remarkably similar’ to those estimates made preceding HAART• Possible reasons – STIs – Risk compensation – cART adherence Jin, 2010 – Viral load (infectivity)
    8. 8. Continued Potential for HIVTransmission among Virally Suppressed • Determine the prevalence of seminal HIV shedding among HIV+ MSM on stable cART. • Of total 101 MSM – 30% detectable HIV DNA and/or RNA in semen – 18% detectable HIV in blood plasma • Of 83 MSM w/ undetectable blood plasma – 25% had detectable HIV in their semen – 11x greater odds of having an STI – 5.5X greater odds of UIAI serosorting (Politch, 2012)
    9. 9. TasP not associated with reductions in HIV incidence among MSM in UK • 40 000 HIV+ UK MSM – 26% undiagnosed – 80% of diagnosed MSM on ART (84% with CD4<350) • Access to & retention in care >95% from 2001-2010 • HIV incidence still climbing because – Risk behavior and increasing STIs – Low annual testing (15 - 25% of all MSM aged 15-59) – Undiagnosed  60%-80% transmissions • 62% of undiagnosed infective (VL >1500 copies/ml ) • 34-60% transmissions primary HIV infection (first few months)(Delpech, IAPAC, 2012)
    10. 10. Co-Occurring Conditions and Amplification of HIV Risk among MSM“AIDS prevention amongMSM has overwhelmingly 0 1 2 3focused on sexual risk alone. % % % %Other health problems among High risk sex 7.1 11.2 15.8 22.5MSM not only are important HIV prevalence 13.0 20.9 27.2 22.4in their own right, but also P<.001may interact to increase HIVrisk. HIV prevention might Psychosocial health problemsbecome more effective by • Poly drug useaddressing the broader health • Depressionconcerns of MSM while also • Childhood sexual abuse history • Partner violencefocusing on sexual risks.”(Stall, AJPH, 2003) Implications for PrEP or ART adherence among PWAS
    11. 11. Mean Community Viral Load among White and Black MSM Living with HIV/AIDS in DC, 2008 50,000Mean Community Viral Load (copies/mL) 45,000 40,000 39,173 35,000 30,000 25,000 20,000 18,283 15,000 10,000 5,000 0 White Black N=762 N=3,395 (West, 2011)
    12. 12. Disparities persist between black and whiteUndiagnosed HIV MSM throughout treatment cascadeOR, 6.38 (4.33-9.39) HIV Diagnosed HIV+ Detection OR, 3.00 (2.06-4.40) ART utilization/ access OR, 0.56 (0.41-0.76) >200 CD4 cells/mm3 before ART initiation OR, 0.40 (0.26-0.62) ART adherence OR, 0.50 (0.33-0.76) HIV suppression OR, 0.51 (0.31-0.83) Viral Suppression (Millett, 2012)
    13. 13. Undiagnosed HIVOR, 6.38 (4.33-9.39) HIV Diagnosed HIV+ Detection OR, 3.00 (2.06-4.40) Health insurance coverage OR,0.47 (0.29-0.77) ART utilization/ access OR, 0.56 (0.41-0.76) >200 CD4 cells/mm3 before ART initiation OR, 0.40 (0.26-0.62) ART adherence OR, 0.50 (0.33-0.76) HIV suppression OR, 0.51 (0.31-0.83) Viral Suppression (Millett, 2012)
    14. 14. Criminalization of Homosexuality & HIV PrevalenceDisparities by Region (Millett, 2012)
    15. 15. Funding Challenges: MSM not targeted proportionate to HIV burden International examples National exmple• Countries that criminalize • Under PA 04012, CDC same-sex awards $300M to 59 HDs – spend less on MSM services each year – less likely to have HIV • In 2009, health departments surveillance for MSM allocated (amFAR, 2011) – 38% of HE/RR funds to high- risk heterosexuals and 27% to• Underfunding for MSM MSM programs via PEPFAR or – 44% of CTR funds to high-risk Global Fund (Health affairs, 2012; heterosexuals and 10% to amFAR, 2011) MSM. (CDC, 2011)
    16. 16. Global HIV prevalence among MSM, 2007-2011Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012
    17. 17. Opportunities
    18. 18. Zeroing on HIV effectiveprevention interventions
    19. 19. HIV Prevention Costs (Monetary and Otherwise)• Modeling cost of various • MSM-GF survey of 5000 prevention modalities to MSM decrease HIV incidence – ¾ low & middle income among MSM over 10 years countries – 39% easy access to free “…seeking health care and disclosing condoms same-sex partners is not safe for MSM in – Oral PrEP global scale many parts of the world, and a 25% easy access to free water- – $26B comprehensive approach to HIV based lubricant prevention requires that we take steps to – Early ART for dx positives change this.” (Sullivan, 2012) $26B • Barriers: knowledge & stigma – Provision of latex condoms – Kenyan sex workers (29% no and water-based lubricant lube & 36% oil-based lube) w $134M condoms (Geibel, 2008) – Jamaican MSM– stigma (Beyrer, 2012) accessing condoms/ lube (Willis, 2011)
    20. 20. ART coverage and reductions in HIV incidence among MSM in DenmarkBiomedical interventions reversing trends • Denmark HIV epidemic isamong MSM driven by MSM • In most Western countries, HIV incidence among MSM is increasing • In Denmark, overall HIV incidence is decreasing – Most HIV+ MSM in care and virally suppressed on ART – No increase in incidence taking place despite increasing risk behavior
    21. 21. Combination prevention for MSM & attaining the National HIV/AIDS Goals (Sorenson & Sansom, CROI, 2011) Interventions Annual # of new HIV % MSM with % Newly dx % Dx w/ infections transmission HIV aware of linked to care undetected (-25%) rate (-30%) status (90%) in 1 yr (85%) viral load (20%)Current practice 1890 7.2% 60.1% 78.1% 64.2% Testing from 1550 6.1% 74.5% 91.8% 60.1% 15%-28% (-18%) (-16%) (-6%) Increase HIV 1868 7.1% 60.9% 78.7% 63.9%awareness from (-1%) (-1%) (0%) 80%-90%Increase linkage 1876 7.1% 60.4% 81.4% 650% to care from (-1%) (-1%) (1%) 70%-85% Increase viral 1675 6.6% 61.6% 78.9% 72.7%load suppressed (-11%) (-8%) (13%) from 80%-90%Tx at diagnosis 1759 6.7% 61.7% 78.6% 72.8% (-7%) (-7%) (14%)Combination of 1054 4.3% 79.1% 98.4% 83.6% all above (-44%) (-40%) (30%)
    22. 22. Population attributable risk and cost analyses in intervention planningInterventions targeting low prevalenceactivities among MSM may be the mostimportant and cost effective in reducing newinfections• Prevalence: 5% reported UAI with HIV+ partner• Impact: Population attributable risk 34%• Cost: $AUD 102M
    23. 23. Evaluating Harm Reduction Activities among MSM• Data from prospective studies of HIV- • Results: negative MSM from – HIV annual incidence in MSM with no US, Canada, Peru, Ecuador, Australia safer-sex strategy was 2.95%. (Vallabhaneni, 2012) – Serosorters, incidence = 1.44% (a 51% reduction) – 100% condom use/no anal sex= 0.76% a• Examined respondents who only year (74% reduction) reported engaging in one of the following – Seropositioning= 0.73% (75% risk reduction activities reduction). – No UAI (47% of the group) – ‘top only’ =0.4% (86% reduction). – Monogamy: UAI, but only within a – Monogamy= 0.25%, a 91.5% reduction monogamous, seroconcordant relationship in HIV risk. (11%) – Insertive UAI only (10%) – Serosorting: UAI HIV negative partners (8%) • However, most men do not engage in – Seropositioning: Insertive UAI with HIV+ or only one of these strategies in their unknown status partners (3%) lifetime – Risky sex: UAI with no risk reduction strategy (21%). • MSM who reported consistent strategy only represented 23% of• Assessed hierarchy or protective effect by sample activity
    24. 24. Risk reduction strategies are complex and vary by context No sex or no UAI Viral load Safe Sex/ Partner reduction Serosorting/ Negotiated Strategic safety Positioning
    25. 25. Thank YouGregorio A. MillettGMillett@CDC.gov

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