The 2015 National HIV Prevention Conference Presentation

Slide 1

High Impact Prevention: Science, Practice, and the Future of HIV

High Impact Prevention: Science, Practice, and the Future of HIV

Jonathan Mermin, MD, MPH

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Centers for Disease Control and Prevention

National HIV Prevention Conference

December 7, 2015

Slide 2

Why are we here when these are 100 percent effective?

Why are we here when these are 100% effective?

Slide 3

Overview

Overview

  • Science and practice of High Impact Prevention
  • State of HIV epidemic including health equity
  • High Impact Prevention 2.0
  • Importance of monitoring and feedback

Slide 4

High Impact Prevention

High Impact Prevention

Slide 5

Prevention with Positives, Prevention with Negatives, Not focused on HIV status

Prevention with Positives

HIV testing, linkage to care and prevention services
Antiretroviral therapy
Retention in care and adherence
Partner services
Risk reduction interventions and condoms
STD screening and treatment
Perinatal transmission

Prevention with Negatives

Behavioral risk reduction interventions and condoms
Pre-exposure prophylaxis (PrEP)
Syringe services
Male circumcision
STD screening and treatment
Post-exposure prophylaxis

Not focused on HIV status

Sexual health education and social mobilization
Condom availability
Substance use, mental health, and social support

Slide 6

Combination prevention for HIV includes multiple disciplines and  approaches.  Interventions can be  structural, community, individual and group, HIV testing and linkage to care and biomedical.

High Impact Prevention

Slide 7

Combination preventionMultiple disciplines and approaches

Combination prevention

  • Multiple disciplines and approaches:
  • Biomedical interventions
  • HIV testing and linkage to care
  • Individual and small group Interventions
  • Community interventions
  • Structural interventions

Slide 8

High Impact prevention includes several steps.  Examine potential interventions, assess efficacy and effectiveness, and  cost-effectiveness, determine feasibility to scale up the intervention, develop economic models, prioritize interventions, and implement and evaluate the programs.

Strategy

Potential interventions

Assess efficacy and effectiveness

Establish cost and cost effectiveness per infections averted and life-years saved

Determine feasibility of full scale implementation

Develop epidemic models to project impact of interventions

Prioritize interventions

Implement and evaluate programs

Slide 9

CDC aligned resources so that the amount of  funding matched the burden of disease.

High Impact Prevention

Slide 10

Implementation of High Impact Prevention

Implementation of High Impact Prevention

  • Program shifts:
    • Most activities focused on priority interventions
    • Doubling of jurisdictions with integrated HIV prevention and care planning
    • Increased activities with PLWHV and MSM, especially black MSM
    • Funding for HE/RR reduced from 34% to 11%
    • Focus on use of ACA and billing capacity
  • About 50% of jurisdictions receive no state HIV prevention resources

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Reducing disparities is good public health

Reducing disparities is good public health

  • Care and Prevention in U.S. (CAPUS)
    • Partnership with CDC, HHS offices, HRSA, SAMHSA
    • $45M total funding over 3 years to 8 states
    • Eligible states had highest HIV burden among African Americans and Latinos, high AIDS diagnosis rates
    • Overcome social determinants that prevent people from reaching a suppressed viral load
    • 25% of resources for CBOs
  • YMSM and Transgender Persons of Color
    • $11 million annually to 34 CBOs to improve care and prevention
    • >3,000 new HIV diagnoses anticipated

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Has it worked?

Has it worked?

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Selected program outcomes

Selected program outcomes

  • States requiring reporting CD4 counts and viral loads increased from 19 in 2011 to 42 in 2015
  • Proportion of persons with HIV who know status highest ever at 87%
    • CDC resources associated with over 1/3rd of HIV diagnoses
    • CDC testing funding correlated with increase in proportion of persons tested for HIV (2.4% increase per $0.34 higher per capita funding)
  • Viral suppression among persons receiving care increased from 72% in 2009 to 80% in 2013

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Some indicators of success

Some indicators of success

  • 2010-14, annual new HIV diagnoses decreased 9%
    • 6% reduction in men; 21% in women
    • 32% decrease in infections attributed to injection drug use
    • 2% decrease in young black MSM, following 114% increase during prior 5 years
  • Proportion of persons with HIV aware of status increased, so decreases not due to less testing
  • 2010-2013, 9% less mortality–seen in all race/ethnic groups
    • 2008-12, mortality among African Americans diagnosed with HIV decreased 28%
    • Hispanic/Latinos have lowest mortality among PLWH

Slide 15

There has been some improvement in the HIV disparities among women with decreasing rates among black/African American women.  However, among men who have sex with men ages 13-24, HIV rates among black/African Americans have not decreased and remain much higher than those among whites and Hispanic/Latinos.

Trends in HIV disparities

Slide 16

Major disparities persist

Major disparities persist

  • HIV prevalence associated with population density, poverty, education, employment, and homelessness, region of residence
  • For disproportionately affected populations, especially MSM and transgender persons, higher prevalence, increased sexual risk require improved coverage of ART, PrEP, education, support services

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HIV prevalence, new diagnoses, and mortality, San Francisco, 2006-2014

HIV prevalence, new diagnoses, and mortality, San Francisco, 2006-2014

Average time to viral suppression reduced from 218 days (2006-9) to 132 days (2010-13)

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High Impact Prevention 2.0

High Impact Prevention 2.0

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Antiretroviral treatment works

Antiretroviral treatment works

  • START trial
    • ART at CD4 count >500 fewer severe adverse events and mortality than delaying therapy
    • 68% of primary endpoints occurred in persons with CD4>500
  • ART reduces transmission of HIV by >96%

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The overall HIV prevalence rate for adults and adolescents was 448 per 100,000.  You can see the highest rate is among blacks, followed by Hispanics, whites, American Indians/Alaska Natives, and Asians/Pacific Islanders.  The HIV prevalence rate for blacks was almost 8 times as high as that of whites. The prevalence rate for hispanics was nearly 3 times the rate for whites.

HIV transmission at each step of care continuum, United States

  • 9 of 10 new infections transmitted by HIV-infected people who are undiagnosed or diagnosed but not in medical care

Slide 21

Reducing HIV risk behavior involves clinical medicine at the center and the involvement of public health and the community.

Clinical Medicine, Community, and Public Health

Slide 22

Data to Care Strategy

High Impact Prevention

Slide 23

PrEP in practice

PrEP in practice

Randomized trials

  • When taken as directed, PrEP prevents >90% of sexually transmitted HIV

PrEP Demonstration Project

  • 2 HIV infections with moderate adherence among MSM and transgender women

PrEP Use, Kaiser Permanent, San Francisco

  • No HIV infections despite high rates of STIs, risk behavior

HIV PrEP demonstration project for YMSM

  • 56% of participants had protective drug level at first visit, but adherence declined
  • 4 HIV infections; all had undetectable drug levels

PrEP empowers

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Prevention as healthcare – Healthcare as prevention

Prevention as healthcare – Healthcare as prevention

  • How do we make HIV prevention services, including PrEP, a normative part of healthcare?
    • HIV testing as routine as cholesterol testing
    • Risk reduction as common as nutrition counseling, foot care for people with diabetes
  • Ensure reimbursement systems support routine HIV prevention services within clinics and by CBOs

Slide 25

New activities

New activities

  • Community-based organization funding
    • $216 million over 5 years; 137 organizations
    • Highly affected jurisdictions and populations
    • Support testing and continuum of care, empowering people to protect themselves, including PrEP
  • State and local health department funding focused on MSM and transgender persons of color
    1. Improve continuum of care, PrEP, risk reduction
    2. Data to Care

Slide 26

CDC, through the Act Against AIDS initiative is launched a new national Testing Campaign called “Doing It. in 2015.   CDC recommends that all Americans aged 13 to 64 get tested at least once for HIV as a routine part of medical care, and that those at high risk get tested at least once a year.   HIV testing is an important component of high impact HIV prevention.   Undiagnosed infection remains an significant factor fueling the HIV epidemic – one analysis found that 30 percent of new HIV infections can be attributed to transmission from people who did not know they were infected.   Nearly one in eight Americans currently living with HIV do not know they are infected and may be unknowingly transmitting the virus to others.   Knowledge your HIV status is empowering. When people test negative, they can assess and modify their risk behaviors to help them stay uninfected. There are more tools available today to prevent HIV than ever before.   When someone tests positive, they can access life-saving medical care and treatment that allows them to stay healthy for many years, and also greatly reduces their risk of transmitting the virus.   You may have already seen some of the campaign creative throughout the hotel venue, but today marks the official launch of this new testing campaign.  There will be a national press release, the onset of national media buys, and a campaign launch event at this evenings NGO/CBO village.   I am excited about this new resource to encourage all Americans—especially those at greatest risk for HIV to get tested for HIV.

Act Against AIDS new National Testing Campaign

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What is the new generation of risk messaging?

What is the new generation of risk messaging?

  • “Protection” is no longer restricted to condoms
  • No studies have assessed effectiveness of risk reduction for HIV-negative persons incorporating ART by partner, PrEP, nPEP, male circumcision, and serosorting
  • Few studies have assessed new approaches for persons with HIV and their partners

Slide 28

HIV Risk Reduction Tool

HIV Risk Reduction Tool

  • User-friendly tool for different audiences of risk estimates and HIV prevention messages incorporating ART, PrEP and new prevention tools
    • Content structured to enable tailoring by user

Slide 29

Condom use

Condom use

  • In national sample, >70% of adolescents reported condom use during last sex
    • However, 22% of women and 25% of men of all ages reported condom use
    • Use more than twice as likely with casual than “relationship” partner
  • Couples stop using condoms over time
    • Men and women >5 times less likely to use condom if had sex >10 times previously
  • Among MSM, 68% of HIV transmission from main partner
    • Higher number of sex acts, more frequent receptive role, and lower condom use

Slide 30

Sexual health education

Sexual health education

  • Good sex education is a counter measure to false information

High Impact Prevention

Slide 31

Teenagers overall have very low rates of injecting drugs – fewer than 2%. However, our data demonstrates some alarming trends that we need to monitor.  First, in selected states and cities that collect these data, we see that among sexual minority youth rates of injection drug use are up to 7 times greater than those of their heterosexual counterparts.

Substance abuse as risk for HIV, hepatitis, and STDs among teens

  • Teens have low risk of injecting drugs—fewer than 2% inject drugs
  • However, in selected states and cities that collect data, sexual minority youth rates of injection drug use up to 7 times greater than those of heterosexuals
  • Many studies show alcohol and drug use associated with HIV and STD risk behavior

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High Impact Program Coordination and Service Integration (HIP PCSI)

High Impact Program Coordination and Service Integration (HIP PCSI)

  • Age-based screening for HIV and HCV using computerized clinical decision tools
  • Annual STD screening of people with HIV
  • STD diagnosis as potential indicator for PrEP, and provision of PrEP at STD clinics
  • Integrated partner services
  • HIV, HCV, and HBV screening and treatment at drug treatment centers

Slide 33

Molecular epidemiology Helping with the basics

Molecular epidemiology Helping with the basics

  • ART resistance testing routinely performed for new diagnoses
  • Reporting by 27 jurisdictions
  • Allows for rapid response to outbreaks and clusters including providing needed social, prevention, treatment services to sexual and drug using networks
  • Precedent with TB where 95% of all TB isolates tested and outbreaks rapidly identified

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HIV and HCV in persons who inject drugs

HIV and HCV in persons who inject drugs

  • Indiana community of 4,300
  • 184 persons with HIV
  • Injecting oxymorphone
  • Majority of HIV infections recently acquired; all but 2 phylogenetically linked
  • Rapid response with contact tracing and testing, one-stop-shop for social services, syringe service program, HIV and HCV testing and treatment, medication-assisted therapy, educational campaign

Slide 35

National and State Progress Reports

National and State Progress Reports

State HIV progress report

  • National goals can be achieved
    • 2015 targets have already been met by one or more states
      • In 5 states 90% or more of people living with HIV know their status, meeting the updated NHAS goal for 2020

Uneven progress

  • More than half of states improved on 6 of 11 indicators
  • Large disparities continue to exist

Slide 36

Think bigger, act faster

Think bigger, act faster

Achieving the prevention goals of National HIV/AIDS Strategy would avert tens of thousands of new infections and save billions of dollars

Slide 37

Conclusions

Conclusions

  • We have turned the corner on HIV, but we are far from achieving success
  • Prioritizing the tools and programs that will have the greatest impact is essential
  • New science, creative education, sound policy, and innovative programs can make easier, more effective choices
  • Future includes integration of treatment, PrEP, molecular epidemiology, and use of data to improve programs
  • Think bigger, act faster

Slide 38

Acknowledgments

Acknowledgments

  • Sara Bingham
  • Rich Wolitski
  • Eugene McCray
  • Stephanie Sansom
  • Irene Hall
  • Janet Cleveland
  • David Purcell
  • Stephanie Zaza
  • Nick DeLuca
  • Dawn Smith
  • Evin Jacobson
  • Patty Dietz
  • Norma Harris
  • Alexa Oster
  • John Brooks
Page last reviewed: October 4, 2019