March 30, 2011
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Message from the Editor
Since our last issue, the Centers for Disease Control and Prevention (CDC) has issued its 2009 HIV Surveillance Report, released interim guidance on preexposure prophylaxis (PrEP) for the prevention of HIV infection in men who have sex with men (MSM) and two updated fact sheets on PrEP, and launched the third wave of phase 1 of the Know Where You Stand campaign to increase HIV testing among black MSM aged 18–44. You will read about these and other HIV prevention highlights as we continue to work together to ensure that we are fulfilling the goals and objectives of the National HIV/AIDS Strategy (NHAS).
On the subject of NHAS, President Obama has committed the federal government to implementing an NHAS that is “grounded in the best science.” Scientific research efforts have greatly expanded our understanding of HIV infection and AIDS and produced many critical tools and interventions to help us diagnose, prevent, and treat HIV infection. Over the past year, we have seen impressive scientific advances in a new rapid HIV test that provides results in 60 seconds, a vaginal microbicide that prevents HIV infection in women, and a PrEP regimen that prevents HIV infection in MSM. To share information and perspectives about recent scientific and technical advances in HIV/AIDS, more than 100 CDC scientists involved with HIV prevention research and practice joined other federal colleagues and 4,000 other scientific experts, providers, and community leaders at the 18th Conference on Retroviruses and Opportunistic Infections (CROI) in Boston, Massachusetts, February 27–March 2. Look for more news about the conference in this issue.
Before we know it, the 2011 National HIV Prevention Conference (NHPC) will be here. Held in Atlanta on August 14–17, the conference will contribute to achieving the three major goals of NHAS—goals that are reflected in the conference theme: The Urgency of Now: Reduce incidence. Improve access. Promote equity. NHAS calls for alleviating the epidemic among gay and bisexual men, transgender persons, and among racial and ethnic populations disproportionately affected by the epidemic. By focusing limited resources on populations and risk groups in geographic areas most affected by the epidemic, the United States can break through the persistent pattern of HIV infection in this country.
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What’s New in HIV Prevention
Estimated Number and Rate of Diagnoses of HIV Infection Remains Stable; AIDS Diagnoses Decrease
Data in the recently released 2009 HIV Surveillance Report show that from 2006 through 2009
- the estimated number and rate of annual diagnoses of HIV infection remained stable in the 40 states with confidential name-based HIV infection reporting since at least January 2006, although estimated numbers and rates of diagnoses of HIV infection increased in some subgroups and decreased in others. Variations in trends between groups may be due to changes in testing behaviors, reporting differences over time, or possibly, changes in the numbers of new HIV infections (incidence) in certain subgroups. The estimated rate of HIV diagnoses in 2009 was 17.4 per 100,000 persons in the 40 states. In 2009, the highest rate of diagnoses—36.9 per 100,000 persons—was for persons aged 20–24 years.
- the estimated number and rate of annual AIDS diagnoses in the United States decreased (based on data from the 50 states and the District of Columbia). In 2009, the estimated rate of AIDS diagnoses in the United States was 11.2 per 100,000 persons compared with 12.1 per 100,000 persons in 2006. In 2009, the highest rate was for persons aged 40–44 years: 27.1 per 100,000 persons.
One of the nation’s primary sources of information on the HIV epidemic, the annual HIV Surveillance Report represents data compiled throughout the country by surveillance coordinators in state and local health departments. This report presents data for cases of HIV infection and AIDS diagnosed through December 31, 2009, and reported to CDC through June 2010.
HIV surveillance data are used by CDC’s public health partners in other federal agencies, health departments, nonprofit organizations, academic institutions, and the general public to help focus prevention efforts, plan services, allocate resources, develop policy, and monitor the HIV epidemic.
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Know Where You Stand Phase of Act Against AIDS Campaign Focuses on Increasing HIV Testing Among Black MSM
Gay, bisexual, and other men who have sex with men (MSM) are the population most severely affected by HIV in the United States—and among MSM, black MSM is the subgroup most disproportionately affected. To encourage HIV testing among black MSM aged 18 to 44 years during the first two waves of CDC’s Know Where You Stand campaign, banner ads were used on select social networking, dating, and blog websites popular with black MSM; HIV testing messages with an inspirational and holistic tone were incorporated into the ads; and 150 billboards promoting HIV testing were placed in six cities (Chicago, Atlanta, Philadelphia, Dallas, Memphis and Orlando) in predominantly black neighborhoods. The importance of HIV testing was also reinforced at Black Pride events.
Wave 3 of the campaign, launched February 7 on National Black HIV/AIDS Awareness Day, consists of online outreach and out-of-home advertising in 14 cities, including advertisements on billboards and the exterior and interior of buses to encourage HIV testing. In wave 3, CDC will continue working with Black Pride and privately produced events as a means to reach the campaign audience with HIV testing messages. As in previous waves, advertising will be placed in event guide books and on event websites to encourage audience members to get tested and drive them to http://hivtest.org/.
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CROI Provides Global Forum for Scientists, Clinicians, and Researchers to Discuss Challenges and Progress in Preventing HIV Infection
From the opening keynote plenary speech on “The Science and Practice of HIV Prevention in the US,” delivered by Dr. Jonathan Mermin, director of the Division of HIV/AIDS Prevention in CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, to a closing symposium on “The HIV Epidemic at 30,” presenters and participants at CROI promoted a better understanding of the prevention and treatment of HIV/AIDS and its complications. Highlighted topics included HIV immunology, HIV transmission and primary/acute infection, preventive HIV vaccines, antiretroviral therapy, HIV drug resistance, AIDS-related malignancies, epidemiology of HIV infection, sexually transmitted infections, and prevention studies on microbicides, pre-exposure prophylaxis, circumcision, and behavioral interventions.
In his speech, Dr. Mermin covered the epidemiology of HIV infection; effective interventions for persons with HIV infection and those who are not infected; high impact prevention—incorporating the components of effectiveness, cost, coverage, feasibility, scale, and prioritization—to maximize the effect of HIV prevention and advance the science of implementation; and implications for research and practice. He concluded that a successful HIV prevention strategy requires prioritizing, targeting, and coordinating resources to maximize effect on incidence and health equity.
Here are synopses of a few of the research presentations:
- Results of a National Institutes of Health study showed that adding one or two drugs to the standard zidovudine (ZDV) treatment reduces the chances by more than 50% that infants born to women whose HIV infections were not diagnosed until they were in labor will develop an HIV infection. From 100 to 200 infants are born with HIV infection in the United States each year (Mother-to-Child (Perinatal) HIV Transmission and Prevention), many to women who either were not tested in early pregnancy or who did not receive treatment during pregnancy. Pregnant women who do not know that they have HIV infection miss the chance for drug treatment that can benefit not only their own health, but could also prevent them from transmitting the virus to their infants.
- Preliminary research suggests that an HIV-fighting gel has the potential to become another weapon in the fight against HIV infection when applied to the rectum before anal intercourse. This is the first time scientists have found evidence that people would tolerate using a gel form of the commonly used antiretroviral drug tenofovir in the rectum. In the new study, the first of three phases needed before the treatment can get approval from the U.S. Food and Drug Administration, researchers tested tenofovir gel, the oral tenofovir pill, and a placebo gel in 18 HIV-negative people who abstained from sex. They took small samples of cells from the rectums of the volunteers, and sent those to a laboratory where they were tested to see how they defended themselves against HIV. Researchers found that a 7-day treatment with the gel performed the best.
- CDC investigators had previously shown that a simple regimen with an oral dose of Truvada given 3 days before virus exposure followed by a second dose 2 hours after exposure protected macaques against repeated rectal exposures with wild-type simian-human immunodeficiency virus (SHIV). Current results show that the same Truvada regimen offered complete protection against rectal transmission of an emtricitabine-resistant SHIV isolate containing the M184V reverse transcriptase mutation.
- Test and treat strategy successes and challenges were explored during a series of presentations. Data from two new studies—one that looked at 1,700 HIV-infected persons in San Francisco and one that followed a large community-based cohort of injection drug users in Baltimore—showed that reduced community viral loads were strongly associated with declines in HIV transmission and incidence. Test and treat programs are based on the premise that using aggressive methods to test and diagnose all people with HIV infection, link them to care, and, when appropriate, get them on antiretroviral treatment will reduce the rate of new HIV infections.
- A rapid HIV testing algorithm (RTA)—in which tests are conducted and provisionally confirmed while the client is present—was implemented in 9 publicly funded HIV counseling and testing sites. In this CDC study, results of testing at these sites were compared with 23 sites conducting rapid HIV testing with off-site confirmatory testing (OSCT). From August 2007 to March 2009, 43,393 persons were tested at OSCT sites and 17,701 were tested at RTA sites. The positive predictive value was 90% for a single test and 100% for the RTA. At OSCT sites, 47% of clients with preliminarily positive results returned for confirmatory test results; all clients with positive RTA results received referral to care in the same visit. Persons who received a referral were more likely (67%) to be in care within 90 days than those who received a preliminarily positive result but did not return for their laboratory results and referrals (49%). Investigators estimated that an additional 189 HIV-positive clients may have been linked to HIV care had the RTA been available at all sites during the study.
Abstracts and webcasts of all sessions, including poster discussions, are available on the CROI website.
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March HIV/AIDS Awareness Days Encourage Discussion About, Promote Action Against the Epidemic
National Women and Girls HIV/AIDS Awareness Day (NWGHHD), observed on March 10, encourages people to take action in the fight against HIVAIDS and raise awareness of its impact on women and girls. Coordinated by the U.S. Department of Health and Human Services' Office on Women's Health (OWH), it is a day for organizations across the country to come together to offer support, encourage discussion, and teach women and girls about HIV prevention, the importance of HIV testing, and living with and managing the disease.
In 2009, one-fourth of Americans diagnosed with HIV infection were women and girls. Since the epidemic began, more than 101,000 women and girls with AIDS have died. Inequities exist in HIV infection among women and girls in the United States, and the greatest burden is among racial and ethnic minority populations. African American/black women and girls are the most disproportionately affected population. An estimated 64% of all women living with HIV infection and AIDS are black.
National Women and Girls HIV/AIDS Awareness Day reminds us that we must continue our collaborations at the federal, state, and local levels—to educate and empower women and girls to know the risk factors for HIV infection, become aware of their HIV status, and access social and medical support if they receive a diagnosis of HIV infection. Find more information at http://www.womenshealth.gov/nwghaad/index.cfm and http://www.cdc.gov/features/womengirlshivaids/.
National Native HIV/AIDS Awareness Day is a collaborative effort between these organizations: Asian & Pacific Islander Wellness Center,CA7AE: HIV/AIDS Prevention Project, Aberdeen Area Tribal Chairmen's Health Board, Inter Tribal Council of Arizona, Inc., and National Native American AIDS Prevention Center. On March 20, we recognize the growing impact of HIV infection and AIDS on our country's Native peoples—American Indians (AIs), Alaska Natives (ANs), and Native Hawaiians. This observance day is an opportunity to collectively and on a national scale raise awareness of the risks of the disease to Native peoples, to help them understand the dynamics contributing to those risks, and to encourage them to get tested for HIV.
Although AIs and ANs represent roughly 1% of the U.S. population, they have historically suffered high rates of health disparities, including HIV infection and AIDS. In 2009, the Native Hawaiian/Other Pacific Islander population ranked third in the nation in the rate of diagnoses of HIV infection. Moreover, AIs, ANs, and Native Hawaiians who are diagnosed with AIDS die sooner after their diagnosis than members of any other ethnic or racial group, suggesting that they may be diagnosed later in the course of infection and have more limited access to health care services. From 2006 through 2009, rates of diagnoses of HIV infection among AIs and ANs increased while rates among other racial and ethnic groups either decreased or remained stable. An estimated 26% of HIV-infected AIs and ANs are unaware of their infection—more than the 21% of HIV-infected Americans overall who do not know they are infected. Lack of access to basic health care services, stigma associated with gay relationships and HIV disease, and high rates of substance abuse, sexually transmitted infections, and poverty all increase the risk of HIV infection and AIDS in Native communities and create obstacles to HIV prevention and treatment.
Through projects such as Commitment to Action for 7th-Generation Awareness & Education: HIV/AIDS Prevention Project, AIs and ANs are working to increase effective HIV prevention and encourage and support early detection through testing in their communities. Decreasing the stigma associated with HIV and AIDS in Native communities and culturally adapting HIV prevention and treatment programs for them can help curb the spread of HIV disease among Native peoples. For more information, visit http://www.happ.colostate.edu/nad.html and http://www.cdc.gov/Features/NativeHIVAIDS/.
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A Model for Allocating CDC’s HIV Prevention Resources in the United States
The article, published online December 24, 2010, in Health Care Management Science describes the methods used to develop a national HIV resource allocation model intended to inform CDC on allocation strategies that might improve the overall effectiveness of HIV prevention efforts. The HIV prevention resource allocation problem consists of choosing how to apportion prevention resources among interventions and populations so that HIV incidence is minimized, given a budget constraint.
To solve the problem, CDC authors Arielle Lasry, Stephanie Sansom, and their RTI coauthors developed an epidemic model that projects HIV infections over time given a specific allocation scenario. The model considers HIV screening interventions and also interventions to reduce HIV-related risk behaviors. The output of the model is the optimal funding scenario indicating the amounts to be allocated to all combinations of populations and interventions.
For illustrative purposes only, a sample application of the model is provided, in which the optimal allocation scenario is compared to the current baseline funding scenario to highlight how the current allocation of funds could be improved. In the baseline allocation, 29% of the annual budget is aimed at the general population, while the model recommends targeting 100% of the budget to the at-risk populations with no allocation targeted to the general population. Within the allocation to behavioral interventions the model recommends an increase in targeting persons with a diagnosis of HIV infection. Also, the model allocation suggests a greater focus on men who have sex with men (MSM) and injection drug users (IDUs) with 72% of the annual budget allocated to them, while the baseline allocation for MSM and IDUs totaled 37%.
Incorporating future epidemic trends in the decision-making process informs the selection of populations and interventions that should be targeted. Improving the use of funds by targeting the interventions and population subgroups at greatest risk may lead to improved HIV outcomes. These models can also direct research by pointing to areas where the development of cost-effective interventions can have the most impact on the epidemic. Read the abstract.
HHS Panel Updates Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
A What’s New in the Guidelines? section summarizes key changes in the current edition of the guidelines, dated January 10, 2011. Throughout the revised guidelines, significant updates are highlighted and fully discussed.
Here are a few highlights:
- Frequency of CD4 determinations can be decreased in stable patients who are virologically suppressed, down to every 6 to 12 months (instead of every 3 to 6 months).
- Virologic failure is now defined as a confirmed viral load >200 copies/mL; this is in response to the higher rates of detection of lower level viremia using the newer assays.
- Timing of antiretroviral (ARV) therapy initiation with TB is updated to reflect results from the SAPiT and CAMELIA studies.
- A new table format provides clinicians with a list of the most common and/or severe known ARV-associated adverse events listed by ARV drug class.
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Highlights of CDC Activities Addressing HIV Prevention among African American Gay, Bisexual, and Other Men Who Have Sex with Men (MSM)
This 6-page brief provides a comprehensive overview of how CDC is addressing the HIV epidemic among African American/black gay, bisexual, and other MSM by
- engaging African American/black gay, bisexual, and other MSM communities and strategic partners,
- expanding and disseminating effective HIV prevention strategies and programs, and
- evaluating and disseminating information on strategies and programs.
The information was presented at the 2011 National African American MSM Leadership Conference on HIV/AIDS and Other Health Disparities in January.
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Webinars Highlight Key Changes to 2010 STD Treatment Guidelines
CDC and the National Network of STD/HIV Prevention Training Centers (NNPTC) hosted the first of a series of live STD Treatment Guidelines webinars for health professionals on January 13, 2011. This webinar has been archived and is now available on the NNPTC and the CDC 2010 STD Treatment Guidelines websites. The 2010 STD Treatment Guidelines Webinar: An Overview by CDC and the NNPTC highlights several key changes to the 2010 STD Treatment Guidelines including the recommended treatment regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum and antimicrobial resistance in gonorrhea and other STDs.
This webinar is intended for clinicians providing care for persons with or at risk for STDs and clinicians and other staff working in health care settings that provide clinical care for persons with or at risk for STDs. This activity has been approved for AMA PRA Category 1 Credit™. At the end of the webinar, participants will be redirected to the California STD/HIV Prevention Training Center’s website where they can register for CME.
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Effect of Transmitted Drug Resistance on Virological and Immunological Response to Initial Combination Antiretroviral Therapy for HIV (Eurocoord-CHAIN Joint Project): A European Multicohort Study
In a new study, published in the Feb. 28 online edition of The Lancet Infectious Diseases, authors estimate that between 10% and 15% of HIV patients in Europe and the United States are infected with a form of HIV that already has at least one drug-resistant mutation.
For the study, 10,056 HIV patients who were beginning combination antiretroviral therapy (cART) for the first time were categorized into three resistance categories: 9,102 patients (90.5%) had no transmitted drug-resistance (TDR); 475 patients (4.7%) had at least one mutation and were receiving fully active cART; and 479 patients (4.8%) had at least one mutation and were resistant to at least one prescribed drug.
Compared with patients without TDR, those with TDR and resistance to at least one prescribed drug were more than three times as likely to experience treatment failure, confirming "the need for at least three fully active antiretroviral drugs to optimize the virological response to a first-line regimen," the authors wrote.
However, the risk of treatment failure was not significantly different between patients without TDR and those with TDR taking a fully active cART regimen containing drugs not compromised by resistance. Read the abstract.
For more information on CDC’s HIV prevention and program activities, read the latest e-HAP Web Updates.
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