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October 26, 2010
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Message from the Editor
Welcome to the October e-HAP FYI, which highlights the HIV crisis in gay and bisexual men and brings you results of new CDC research that underscores the severity of the epidemic in this population. We invite you to read about new efforts to address the epidemic in the gay community, including information on CDC’s expanded HIV testing program that increases HIV testing opportunities and expands prevention and care services for gay and bisexual men and other disproportionately affected populations. Find out how CDC is allocating $29.2 million in resources to support the National HIV/AIDS Strategy and how the agency is expanding its
Act Against AIDS Leadership Initiative. Read about the three national HIV/AIDS awareness days commemorated in September and October. There is also news about the test and treat strategy and how our federal partners are evaluating this strategy to identify, treat, and retain in care HIV-positive inmates and parolees. Take a look back at the U.S. Conference on AIDS, and learn about new treatment challenges in children taking antiretroviral therapy (ART).
We welcome and encourage your suggestions and feedback. To provide feedback, please contact the Office of Communications at
DHAPCommunications@cdc.gov.
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What’s New in HIV Prevention?
CDC Awards $29.2 Million to Expand HIV Prevention Efforts Under the National HIV/AIDS Strategy (NHAS)
 This FY 2010 increase in funding represents an exciting new investment in HIV prevention and will help focus HIV prevention efforts on highly affected populations and communities, as well as fill critical gaps in data, knowledge, and understanding of the epidemic. The funding is an important step in implementing prevention approaches outlined in NHAS to reduce HIV infection in the United States.
Grants totaling $11.6 million will support demonstration projects to identify and implement a combination approach to enhance effective HIV prevention programming—inclusive of treatment, care, and social services—in 12 hard-hit areas across the country. Each funded jurisdiction will work with CDC to determine what mix of HIV prevention approaches can have the greatest impact in the local area, supplementing existing programs in these communities and helping jurisdictions to better focus efforts on key at-risk populations and fulfill unmet needs. Efforts will follow a basic approach of intensifying prevention for persons at greatest risk, and testing them to reduce undiagnosed HIV infection; prioritizing linkage to prevention, care, and treatment services for people living with HIV; and directing these intensified efforts to communities with the highest burden of HIV.
The remainder of the resources will allow CDC and our partners to expand upon successful existing efforts, as well as fill knowledge gaps to help guide evidence-based policies and approaches as a part of the NHAS by
- Increasing HIV testing: $4.4 million will allow CDC to further expand its successful HIV testing initiative.
- Filling critical data gaps: $5.6 million will enhance local area data collection, and provide critical information to better monitor and target future HIV prevention and treatment programs.
- Supporting evaluation for new activities: $6.6 million will support evaluation and monitoring of combination prevention approaches and other activities. Funding will also establish a web-based survey to more quickly identify and respond to trends in risk behavior and exposure to HIV prevention services among gay and bisexual men.
- Prioritizing underserved populations: $1 million will support work with tribal communities to improve HIV prevention and program integration for American Indians and Alaska Natives.
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HIV Testing Program Expands Routine Testing Services to New Clinical and Non-Clinical Venues to Reach a Broader Array of At-Risk Populations
On September 30, health departments in 30 jurisdictions with the highest burden of AIDS among populations hardest hit by the HIV epidemic began using funds awarded under FOA PS10-10138:
Expanded Human Immunodeficiency Virus (HIV) Testing for Disproportionately Affected Populations. The purpose of this program is to expand routine HIV testing services for African American and Hispanic men and women, and men who have sex with men (MSM) and injection drug users (IDUs) of all races and ethnicities. This program represents one of the ways CDC can help state and local health care providers to
- make HIV testing routine and advance diffusion and implementation of CDC’s 2006
Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings;
- identify more HIV-positive persons in these disproportionately affected populations, and increase the proportion of persons who are aware of their infection;
- expand HIV counseling, testing, and referral services in non-clinical settings or venues—such as homeless shelters, bars, syringe exchange programs, and Gay Pride events—where members of these populations at highest risk for HIV infection can be reached; and
- integrate HIV testing with testing and prevention services for other infections, such as other sexually transmitted diseases (STDs), hepatitis B and C viruses, and tuberculosis.
The program—by placing greater emphasis on post-test services for both persons who are newly diagnosed with HIV infection and persons who have previously tested positive for HIV, but were not successfully linked to or retained in care—can better address the continuum of services and programmatic activities needed to translate increases in routine HIV screening into community-level decreases in HIV transmission, undiagnosed infections, and HIV-associated morbidity and mortality.
This phase substantially extends the geographic and demographic reach of the initial phase of CDC’s expanded testing program, first funded in 2007. More funding boosts the number of funded jurisdictions from 25 in 2007 to 30 for the 3-year project period that has just begun. These jurisdictions now have greater support to monitor and evaluate their programs; market routine HIV screening to both patients and providers; and link persons diagnosed with HIV infection to critical prevention, treatment, and social services.
In the first 2 years of the initial 3-year testing program, more than 1.4 million persons were tested for HIV infection; of the more than 10,500 HIV-infected persons newly diagnosed, 75% were linked to care.
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NHBS Data Highlight Need to Increase Access to HIV Testing for Gay and Bisexual Men
 HIV testing and survey results from CDC’s 2008 National HIV Behavioral Surveillance system (NHBS) show that about 1 in 5 (19%) gay, bisexual, and other men who have sex with men (MSM) in 21 major U.S. cities have HIV infection—and that nearly half (44%) do not know they are infected. Among the 8,153 MSM tested, HIV prevalence was 28% among blacks, 18% among Hispanics, and 16% among whites. Black MSM were less likely than other MSM to be aware of their HIV infection: 59% were unaware compared with 46% of Hispanic and 26% of white MSM.
In these cities, young MSM—especially young MSM of color—were far less likely than older men to realize they were HIV infected. Among those under age 30 who were infected, nearly two-thirds (63%) were unaware of their HIV status. The findings, published September 24 in CDC’s
Morbidity and Mortality Weekly Report (MMWR), also show a strong link between socioeconomic status and HIV infection among MSM in these cities. Prevalence increased as education and income decreased, and awareness of HIV infection was higher among MSM with more education and higher income. The economic disparities described in this report are consistent with those reported among heterosexuals participating in NHBS and reinforce the need for directing prevention efforts to low-income populations.
Because MSM represent the only group with increasing HIV incidence and comprise the largest proportion of new infections—in 2006, 57% of new HIV infections in the United States occurred among MSM (including MSM who inject drugs) —targeting resources and prevention strategies to gay and bisexual men is critical. The National HIV/AIDS Strategy emphasizes the importance of improving the impact of HIV prevention efforts for gay and bisexual men, and the President’s 2011 budget includes $27 million in new CDC funds to support additional HIV and STD prevention programs for gay, bisexual, and other MSM. The current NHBS data also underscore the specific need for increased HIV testing efforts for MSM, especially minority MSM. As the previous article conveys, CDC recently broadened its expanded HIV testing initiative to reach more gay and bisexual men.
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CDC Expands Leadership Initiative to Reach Most Vulnerable Groups
CDC recently expanded its successful Act Against AIDS Leadership Initiative (AAALI), increasing the effort’s funding from $10 million to $16 million over 6 years and expanding its scope to include 8 additional organizations to help fight HIV among African Americans, Latinos, and gay and bisexual men—the populations hardest hit by the HIV epidemic.
Launched in 2009 at the same time as the Act Against AIDS national HIV prevention and communication campaign, AAALI brings together some of the nation’s foremost African American organizations to intensify HIV prevention efforts in black communities. The AAALI expansion adds five African American organizations, two focused specifically on black gay and bisexual men, and three Latino organizations.
Within its first year, AAALI partners coordinated nearly 1,400 outreach events, connecting with more than 200,000 people; engaged nearly 400 of their local affiliates across the United States in prevention activities; and reached millions more with critical HIV prevention messages through conferences, advertisements, and media stories.
The expanded initiative represents CDC’s ongoing commitment to increase access to HIV prevention for those who are most vulnerable to this disease, and directly supports the priorities identified in the National HIV/AIDS Strategy to focus on populations most affected by HIV infection.
For more information and a list of the current 19 AAALI partners, read the
press release.
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September and October National HIV/AIDS Awareness Observances Accent Severity of the Epidemic in Hispanics/Latinos and Gay and Bisexual Men, and Complexity of the Disease in Older Adults
 The theme of the eighth annual
National Latino AIDS Awareness Day on October 15—Save a Life, It May Be Your Own. Get Tested for HIV—affirmed the critical roles HIV testing and prevention education play in preventing the spread of HIV. Hispanics/Latinos account for a disproportionate share of diagnoses of HIV infection in comparison to American Indian/Alaska Natives, Asians, Native Hawaiians/other Pacific Islanders, whites, and persons reporting multiple races. From 2005–2008, Hispanics/Latinos accounted for 20% of the total estimated number of diagnoses of HIV infection in the 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. During this period, Hispanics/Latinos accounted for 17% of the women diagnosed with HIV infection and 18% of all diagnosed HIV infections attributed to heterosexual contact. Gay and bisexual Latino men remain hardest hit. Among Hispanic/Latino males in 2008, 69% of diagnosed HIV infections were attributed to male-to-male sexual contact. Data from CDC's National HIV Behavioral Surveillance System, referenced in an earlier article, show that, in 2008, 46% of HIV-infected Hispanic MSM did not know they were infected, compared with 26% of white MSM.
According to a new
CDC study of HIV infection among Hispanics/Latinos in Puerto Rico and 37 states in 2007, the estimated lifetime risk (ELR) of being diagnosed with HIV is 1 in 36 for Hispanic males and 1 in 106 for Hispanic females. The overall risk that Hispanics/Latinos will be diagnosed with HIV in their lifetime is 1 in 52. This latter rate compares with an ELR for HIV diagnosis of 1 in 170 for whites and 1 in 22 for blacks.
A range of factors place Latinos at high risk for HIV infection and may prevent them from seeking needed HIV testing and treatment, including lack of awareness about HIV infection; cultural and socioeconomic factors such as poverty and language barriers; concerns about immigration status; and homophobia and stigma. Late HIV diagnosis among HIV-infected Latinos is a key concern, and many Latinos are not getting antiretroviral treatment at an earlier stage in their infection when medication could produce the best health outcomes. Read
additional information about National Latino AIDS Awareness Day and information about
CDC activities and HIV resources for Latinos.
On September 27, we commemorated the third annual
National Gay Men’s HIV/AIDS Awareness Day. Although it has been almost 30 years since the first reported cases of HIV among gay and bisexual men, HIV remains a crisis in this community. MSM are the only risk group for which new infections are increasing, representing more than half (57%) of those with new HIV infections in the United States each year. Moreover, more than half (53%) of people living with HIV infection are gay or bisexual men or MSM who inject drugs. Although MSM account for just 4% of the U.S. male population aged 13 and older, they have a rate of new HIV diagnoses more than 44 times that of other men.
Gay and bisexual men with multiple partners face an increased risk of infection, as do those who use drugs during sex. Many gay and bisexual men are not tested or retested regularly because they are afraid they may be infected—and if they are, not knowing their HIV status hinders life-saving treatment and puts their partners at risk. Undeniably, stigma, homophobia, and discrimination are compelling issues that may prevent gay and bisexual men from accessing the prevention and treatment resources they need.
Studies show that once people learn they are HIV infected, most take steps to protect their partners. CDC recommends that gay and bisexual men get tested at least yearly or more often if at increased risk. An updated CDC
online resource focused on the health of gay and bisexual men brings together important information and connects users to health resources specifically for gay and bisexual men. See a
statement by Dr. Kevin Fenton, Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, and a
Dear Colleague letter from Dr. Jonathan Mermin, Director, Division of HIV/AIDS Prevention.
Older HIV-infected adults—including older gay and bisexual men—face unique health challenges stemming from age-related changes to the body accelerated by HIV infection, the side effects of long-term treatment for HIV, the infection itself, and, often, treatments for age-associated illnesses. The 50 and older population is the fastest growing population in the world. In 2008, the 50 and over population comprised about 25% of the total U.S. population. September 18, which marked the third annual
National HIV/AIDS and Aging Awareness Day, provided an opportunity to highlight these challenges and the research under way to improve the health and quality of life of older people with HIV infection. The awareness day also provided an opportunity to educate older Americans about risk factors for HIV transmission and to encourage them to get tested for HIV.
According to CDC, in 2007, persons aged 50 and older accounted for 16% of new HIV/AIDS diagnoses, 27% of persons living with HIV infection, 33% of persons living with AIDS, 19% of all AIDS diagnoses, and 38% of deaths of those living with AIDS. By 2015, more than half of those infected with HIV will be older than 50 years of age.
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New Study on the Epidemiology of HIV in Major Urban Areas Shows Epidemic Remains Concentrated in Gay Men
In an article published September 15 in PLoS One, authors from CDC’s Division of HIV/AIDS Prevention (DHAP), the Chicago Department of Public Health, and the Los Angeles County Department of Public Health used national HIV surveillance data for 12 metropolitan statistical areas (MSAs) with the greatest HIV burden to determine disparities in HIV diagnoses and prevalence. In 7 of the 12 MSAs, more than 50% of HIV diagnoses in 2007 were attributed to male-to-male sexual contact. In each MSA, prevalence was >1% among blacks; and prevalence among blacks was >2% in Miami, New York, and Baltimore. Among Hispanics, prevalence was >1% in New York and Philadelphia. Prevalence generally was even higher in cities within MSAs, with HIV prevalence among whites above 1% in Washington, DC, and above 2% in San Francisco. Although heterosexual transmission surpassed or equaled male-to-male sexual transmission in Baltimore, Philadelphia, and Washington, DC, in several MSAs—including Baltimore and Washington, DC—AIDS diagnoses in recent years have increased among men who have sex with men.
This article is the first report using national surveillance data to describe the epidemic of HIV in urban areas. These data are useful for identifying local drivers of the epidemic and for tailoring public health efforts for treatment and prevention services for persons living with HIV.
Read the article.
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U.S. Conference on AIDS (USCA)
 In mid-September, division staff and leaders joined Health and Human Services (HHS) leaders and more than 2,000 other HIV/AIDS public health workers and advocates, physicians, policymakers, and persons living with HIV and AIDS at USCA in Orlando to exchange the latest information and learn about the best strategies to address the challenges of HIV/AIDS. Three DHAP leaders—Jonathan Mermin, director; Janet Cleveland, deputy director for prevention programs; and Richard Wolitski, deputy director for behavioral and social science—participated on a panel about the
National HIV/AIDS Strategy (NHAS). They emphasized that the strategy gives the HIV prevention community an opportunity to redefine our nation’s approach to HIV prevention and signals a time of optimism, promise, and urgency.
Speaking at the conference’s opening session, HHS Secretary Kathleen Sebelius acknowledged all the AIDS service providers at the conference “who work every day in neighborhoods around the country to overcome stigma, increase screenings, reduce infections, treat illness, and spread hope.” She committed to intensifying prevention efforts in communities where infections are concentrated and added, “We’re going to put our resources where the risk is. To help us do that, we’ve committed $30 million from an unprecedented new Prevention and Public Health Fund created by the Affordable Care Act to support new and existing HIV prevention efforts. These funds will allow us to focus on the communities and geographic areas that have been hardest hit by this disease. And we recently updated our budget request for next year to request $35 million for these essential prevention efforts.”
A closing session on NHAS featured other HHS leaders—Howard Koh, assistant secretary for health; Ronald Valdiserri, deputy assistant secretary for
health, infectious diseases; and Jeffrey Crowley, director of the Office of National AIDS Policy—as well as other federal and community leaders.
About 15 division staff gave oral presentations or participated on panels at the conference, highlighting program activities and new research that will advance our collective HIV prevention efforts. Topics included new interventions, ¡Cuídate! and AIM, for Latino and black youth; Internet-based methods for reaching higher-risk MSM; and linkage of community mobilization models to evidence-based prevention programs.
Read a
wrap-up of the conference.
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NIH Funds Grantees to Identify, Treat, and Retain in Care HIV-Positive Inmates, Parolees, and Probationers
Twelve scientific teams in more than a dozen states will focus on identifying persons with HIV and AIDS within the criminal justice system and linking them to antiretroviral therapy during periods of incarceration and after community re-entry. The grantees will apply the “seek, test, and treat” strategy to inmates in jails and prisons across the United States—a population disproportionately represented by minorities and disproportionately affected by HIV infection, other STDs, and hepatitis infections. Each year, an estimated 1 in 7 persons with HIV infection passes through a correctional facility.
Some of the projects will create and compare systems to better integrate and coordinate HIV management efforts within jails, prisons, health departments, universities, and community organizations. The grants will also support randomized controlled trials among large groups of HIV-positive parolees and probationers and compare varied approaches for linking them to screening, treatment, and social services in their communities.
Research has shown that many persons who are detained in correctional facilities have limited access to health care and HIV prevention services after they are released back into their communities, and often struggle with obtaining basic needs such as housing. “Screening incarcerated persons for HIV and linking persons with HIV to appropriate care and treatment services inside the facility and following their release from custody is critical,” according to Robin MacGowan, senior research officer in DHAP’s Prevention Research Branch.
“These research grants will provide valuable information in advancing the field of HIV prevention for incarcerated individuals, and will further the efforts that CDC has promoted in increasing routine voluntary HIV testing in correctional facilities,” he added.
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CDC Study on HIV Patients' Entry and Retention in Care Assesses Potential Success of “Test and Treat” Strategy
In their article, “Entry and Retention in Medical Care among HIV-Diagnosed Persons: A Meta-Analysis,“ published ahead of print on September 14 in AIDS, DHAP authors examine the proportion of persons diagnosed with HIV infection in the United States who enter care soon after their diagnosis and the proportion who are retained in care. The study found that 69% of HIV patients overall entered care following their diagnosis, and that overall 59% of these patients were retained in care. Although their findings are encouraging, the authors conclude that improvement in entry and retention in care rates will increase the success of a “test and treat” strategy.
Read the abstract.
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Anal Cancer Is Increasing Among People with HIV Infection
In the September Gay Men’s Health Crisis (GMHC)
Treatment Issues  , read about how anal cancer is emerging as a common non-AIDS defining cancer in persons with HIV infection. Anal cancer, like cervical cancer, is caused by infection with high-risk types of papillomavirus (HPV); low-risk types of the virus can cause genital and anal warts. In the age of antiretroviral therapy, the rate of anal cancer appears to be increasing. In a recent analysis from Kaiser-Permanente, the rate of anal cancer among the HIV-positive population was estimated to be 174/100,000 person-years—and even higher among persons with lower CD4+ counts—compared with 2/100,000 person-years among the HIV-negative population. This rate is significantly higher than the rate of cervical cancer before PAP screenings were routinely performed on women (35/100,000).
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Kids on HAART May Need to Be Revaccinated to Maintain Their Immunity Against Preventable Childhood Diseases
In an
article in the September issue of The Lancet Infectious Diseases, researchers from Johns Hopkins reviewed 38 published studies and found that most children treated with highly active antiretroviral therapy (HAART) are still susceptible to vaccine-preventable diseases but respond well to revaccination. Fewer children infected with HIV achieve protective immunity, and those who do could experience greater and more rapid waning of immunity. According to the authors, these results suggest that children on HAART would benefit from revaccination.
Currently, there are no official recommendations on revaccination of HIV-infected children on HAART. As treatment programs scale up and more children receive HAART and live into adolescence and adulthood, a larger proportion of these children could be susceptible to childhood diseases.
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9½ Minutes Ad on Times Square Jumbotron Keeps HIV in the Minds of American Public
 Thanks to the HHS Office of the Assistant Secretary for Public Affairs, the 9½ minutes message—Every 9½ minutes, someone in the United States is infected with HIV—was recently spotlighted on a Times Square jumbotron. From September 1 – October 15, the 9½ minutes ad rotated with an ad for flu.gov, with each 15-second ad running twice an hour, for 16 hours per day.
9½ Minutes, the first phase of the
Act Against AIDS campaign, was launched last year to refocus national attention on the U.S. HIV epidemic and to re-engage every American in the fight against HIV by combating complacency, increasing testing, and raising awareness of the severity of epidemic.
The Jumbotron is a state-of-the-art, full-motion, full-color screen totaling 520 square feet (26’ wide by 20’ high). CDC estimates the ad generated approximately 1.5 million media impressions per day.
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Resources
View upcoming conferences and observances.
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