HIV Prevention

Centers 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

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New HIV Infections (Incidence)People Living With HIV/AIDS (Preva-lence)

JAMA 2008;300(5):520-529.Campsmith M, et al. CROI 2009.

HIV Incidence and Prevalence, United States, 1977–2006

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 women

CDC, 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

contactincreased — 37 states and 5 U.S. dependent

areas

2005 2006 2007 20080

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Year of diagnosis

Dia

gn

oses,

%

Male-to-male sexual contact

Heterosexual contact1

Injection drug use

Male-to-male sexual contact and injection drug use Other2

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.

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

72%

15%

9%

4% <1%

MalesN=31,595

84%

15%

1%

FemalesN=10,662

Heterosexual contacta

OtherbMale-to-male sexual contact Injection drug use (IDU)Male-to-male sexual contact and IDU

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

2005 2006 2007 20080

10

20

30

40

50

60

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.

Black/African American

Hispanic/Latinoa

White

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

Multiple races

Year of diagnosis

Dia

gn

oses,

%

HIV prevention worksSaves 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 strategies

Promote: 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

Cost of condoms

~$400,000

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 saved

Source: 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 acquisition

Source: Grant RM et al. (2010). NEJM; published online Nov. 23, 2010.

Policy, Systems, and Environmental Change

Integrating Prevention and Healthcare

Policy 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 Healthcare

New 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 treatment

Source: 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 confirmed

Source: 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 HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

—Vision of the National HIV/AIDS Strategy