CDC’s HIV Prevention Priorities and Activities

1. CDC’s HIV Prevention Priorities and Activities M. Christine Cagle, PhD Associate Director for Policy and Planning Division of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention April 9, 2008

2. Presentation Outline • CDC HIV Prevention Strategic Plan: Extended Through 2010 • Priority Initiatives • Programmatic and Scientific Priorities (2008-2010) • Priority Recommendations/Guidelines • Implementation of Early Diagnosis Program

3. CDC HIV Prevention Strategic Plan – Extended Through 2010 • Guiding Policy • Goals modified with baselines and targets • 42 objectives • 17 performance indicators • More explicit focus on African American and MSM communities • New objectives added that • address advances in understanding about importance of acute HIV infection, the role of incarceration in the HIV epidemic, and technical advances in HIV rapid testing. • underscore the priority to increase HIV screening in medical settings. • reflect recent data about disparities in knowledge of one’s HIV infection, especially among MSM.

4. CDC HIV Prevention Strategic Plan – Extended Through 2010 • Short-Term Goal: “Reduce the number of new HIV infections in the United States by 5% per year, or at least by 10% through 2010, focusing particularly on eliminating racial and ethnic disparities in new HIV infections.” • Short-Term Milestone 1: By 2010, decrease by at least 10% the number of persons in the United States at high risk for acquiring or transmitting HIV infection by delivering targeted, sustained and evidence-based HIV prevention interventions. • Short-Term Milestone 2: By 2010, decrease by at least 10% the number persons in the United States at high risk for acquiring or transmitting HIV infection by delivering targeted, sustained and evidence-based HIV prevention interventions. • Short-Term Milestone 3: By 2010, increase from the current estimated 50% to 65% the proportion of newly diagnosed HIV-infected people in the United States, who are linked to appropriate prevention, care and treatment services. • Short-Term Milestone 4: By 2010, strengthen the capacity nationwide to monitor the epidemic, develop and implement effective HIV prevention interventions and evaluate prevention programs.

5. Key FactsMen who have Sex with Men (MSM) • Of the 28,378 reported AIDS cases among males in 2006, 49% reported male-to-male sexual contact • MSM is the largest population living with HIV (45%) • Males accounted for 73% of all new HIV diagnoses in 2006, most diagnoses (67%) were for MSM. • MSM is the only risk group where prevalence rates are increasing. • Among MSM, rates of HIV for Black MSM are rising in the age groups of 13-24. • Of the estimated 333,244 male adults and adolescents living with AIDS, 60% had been exposed through male-to-male sexual contact.

6. CDC Prevention Activities for MSM Internal Division Executive Committee Interventions for MSM Community level – MPowerment Testing Methods – PCRS, Venue Testing Social Networks New Behavioral Interventions & Research projects – specifically focusing on Black MSM Program Announcements specifically targeting MSM and YMSM of Color Comprehensive Action Plan with recommendations and action steps for Black MSM

7. Key FactsAfrican Americans and HIV/AIDS Of the 37,911 AIDS cases reported to CDC in 2006, African Americans accounted for 49% of the total, 31% of men, 17% of women Of the 38 estimated number of AIDS cases in children < less than 13 years of age, African Americans accounted for 79%. Of the more than 1 million Americans estimated to be living with HIV, 47% are African American African Americans account for about 13% of the population but they accounted for nearly half of new HIV diagnoses (49%) in 2006 (data from 33 states). African Americans accounted for 70% of the proportion of HIV/AIDS Cases among Adolescents 13-19 years of age. African American men have the highest rates of HIV/AIDS diagnoses of all racial/gender groups AIDS rates (males): x7 Whites; x2 Hispanics; x12 API. African American females have the highest rates of HIV/AIDS diagnoses of all females: AIDS rates (females): x19 Whites; x4 Hispanics; x17 API; x12 AI/AN

8. Female Male Cases per 100,000 population Estimated Rates of HIV/AIDS Diagnoses among Adults and Adolescents, 2006—33 States Note: Data from 33 states with confidential name-based HIV infection reporting since at least 2001. Data have been adjusted for reporting delays.

9. Heightened National Response to HIV/AIDS In African American Community

10. HNR Launch Event • 80 leaders attended launch event held March 8, 2007 • Majority represented media and AIDS Service Organizations (14%), faith and health (13%), civil/social organizations (11%), and arts and entertainment (8%) • Leaders made commitments in three activities: • Awareness – Break the silence and increase awareness of HIV/AIDS among friends, family, and co-workers • Communications – Increase communication in places where African Americans live, work, play and worship • Testing – Promote testing that will lead to early diagnosis and treatment of HIV/AIDS

11. Four HNR Strategies • Expand the reach of prevention services CDC is: Increasing investment in prevention programs serving African Americans and enhancing culturally appropriate strategies for delivering services to this population CDC asks Partners to: Build linkages with other organizations that provide related social and health services to African Americans • Increase opportunities for diagnosing and treating HIV/AIDS CDC released revised recommendations for HIV screening of adults, adolescents, and pregnant women in health -are settings in 2006 CDC funded FY 2007 HIV Testing Initiative • $35 million to 23 jurisdictions • Majority of funds to health departments to increase HIV testing opportunities for populations disproportionately affected by HIV—primarily African Americans who are unaware of their HIV status

12. Four HNR Strategies • Develop new, effective prevention interventions for African Americans CDC is: Initiating new research projects to test newly developed, community-based, or adapted interventions for African Americans at increased risk for contracting or transmitting HIV CDC asks Partners to: Involve African American community stakeholders in developing and implementing research designs that address a range of issues related to accessing HIV prevention, treatment, and care • Mobilize broader community action CDC is: Developing new channels for communicating about the impact of HIV/AIDS on African American families and communities, and the consequences of silence and stigma about HIV CDC asks Partners to: Break the silence and increase awareness of HIV/AIDS among friends, family, co-workers, and others within African American communities

13. HNR Leaders’ Commitments – 1 Year Progress • Total of 94 commitments made by 67 leaders. • As of February 2008: • 42 commitments (45~) have been completed • 34 commitments (~37%) are in progress • 76 commitments (~82%) have been completed or are in progress • Examples of commitments: • Lyfe Jennings, Recording Artist – recorded hit single, “AIDS, It’s Real,” • Darian “Big Tigger” Morgan (Street Corner Foundation) – promoted National HIV/AIDS Testing Day and emphasized importance of testing during 7th Annual BET Awards telecast, broadcast to 6.4 million viewers • Aetna Healthcare - Defined HIV/AIDS a priority health area of Aetna • Dr. Ronald Mason, Jackson State University – Penned letter to presidents of HBCUs explaining importance of education sector’s participation in HIV/AIDS awareness, prevention, and testing; and established an AIDS Awareness Fund at Jackson State with initial commitment of $30,000

14. Key FactsHispanic/Latinos and HIV/AIDS • Appropriately 17% of the more than 1 million Americans living with HIV are Hispanic • Hispanics account ~13 of population, they compromise 18% of new HIV/AIDS diagnoses (33 states with HIV reporting) • Rate of HIV/AIDS diagnoses for Hispanic males (50.9) is more than 3 times higher than rate among white males (18.2) • Rate of HIV/AIDS diagnoses for Hispanic females (15.1) is more than 5 times higher than among white females • Of the proportion of AIDS cases (37, 911) reported in 2006, 19% were among Hispanics • Infection routes vary greatly by place of birth • MSM infection more common among those born in U.S. South America, Cuba, and Mexico • Heterosexual infection more common for those born in Central American and Dominican Republic • Injection Drug Use infection more common in Puerto Rico Account for 1:3 MSM diagnosed with HIV/AIDS in 2005

15. CDC Prevention Activities for Hispanics/Latinos • In 2007, Division of HIV/AIDS established internal executive committee to develop a plan of action to reduce the number of new HIV infections among Hispanics/Latinos and increase access to culturally appropriate prevention, care, and treatment services. • Division is expanding its partnerships with other federal agencies, state and local health departments, academic institutions, and community-based organizations to facilitate implementation of the Plan of Action. • Hispanic/Latino Consultation held April 1-2 in Atlanta • Approximately 110 community leaders and representatives from various Hispanic/Latino-serving institutions participated • Consultation examined multiple issues affecting domestic HIV/AIDS epidemic among Latino/Hispanic-epidemiology, current evidence-based interventions, socio-cultural factors, best practices, and challenges and opportunities.

16. CDC Prevention Activities for Hispanics/Latinos, cont. • Conducts epidemiologic and behavioral research focused on Hispanics/Latinos • Supports efforts to reduce the health disparities experienced in communities of minority races and ethnicities at high risk for HIV infection • Provides effective, scientifically based interventions to organizations serving Hispanics/Latinos and tailoring other effective behavioral interventions to Hispanics/Latinos who are at high risk for HIV infection • Builds capacity of programs that service Hispanics/Latinos through partnerships with national, regional, and non-governmental organizations • In 2006, provides 56 awards to CBOs in the U.S. and Puerto Rico that focus primarily on Hispanics/Latinos • Consultation recommendations will be used to develop Action Plan for addressing HIV among Hispanics/Latinos

17. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care SettingsMMWR 2006;55(No. RR-14):1-17Published September 22, 2006 http://www.cdc.gov/mmwr/pdf/rr/rr5514.pdf

18. Revised RecommendationsAdults and Adolescents - I • Intended for all health care settings, including inpatient services, EDs, urgent care clinics, STD clinics, TB clinics, public health clinics, community clinics, substance abuse treatment centers, correctional health facilities, primary care settings • Routine, voluntary HIV screening for all persons 13-64 in health-care settings, not based on risk • Repeat HIV screening of persons with known risk at least annually • Opt-out HIV screening with the opportunity to ask questions and the option to decline

19. Revised RecommendationsAdults and Adolescents - II • Include HIV consent with general consent for care; separate signed informed consent not recommended • Provide clinical HIV care or ensure referral to qualified providers • Prevention counseling in conjunctions with HIV screening in health-care settings is not required • Communicate test results in same manner as other diagnostic/screening tests

20. Revised RecommendationsPregnant Women - I • Universal opt-out HIV screening • Include HIV in routine panel of prenatal screening tests • Consent for prenatal care includes HIV testing • Notification and option to decline • Second test in 3rd trimester for pregnant women: • Known to be at risk for HIV • In jurisdictions with elevated HIV incidence • In high HIV prevalence health care facilities

21. Revised RecommendationsPregnant Women - II • Opt-out rapid testing with option to decline for women with undocumented HIV status in L&D • Initiate ARV prophylaxis on basis of rapid test result • Rapid testing of newborn recommended if mother’s status unknown at delivery • Initiate ARV prophylaxis within 12 hours of birth on basis of rapid test result

22. State and Local Considerations • Some require specific written & signed consent • Some require specific counseling • Pre-test counseling • Specific training & certification requirements for individuals providing pre-test counseling • Test results must be given face-to-face by trained individuals • Screening can be implemented now within current laws, rules, and regulations

23. Legislative Changes Since 2006 Removed separate written consent requirement California - Iowa - Illinois Indiana - Louisiana - Maine New Hampshire - New Mexico Authorized opt-out prenatal testing Georgia - Iowa - Illinois Louisiana - Nevada - Rhode Island Tennessee - New Jersey

24. Implementation Guidance for HIV Testing in Health-Care Settings • Departments • Inpatient Services • Emergency Community Health Centers • Substance Abuse Clinics • Adult Primary Care Settings • STD Clinics • Adolescent Medicine & Pediatrics • Correctional Facilities • Labor & Delivery

25. Reimbursement • Work with health insurers to seek reimbursement for HIV screening • CDC is working with insurance trade association, “America’s Health Insurance Plans” • Medicare does not pay for screening – screening must be specifically authorized by Congress • NY & CA Medicaid have specifically committed to reimburse for HIV screening • New York Medicaid: $130 • California Medicaid: $12.65 • HIV screening needs to be “standard of care” versus “medically necessary” for insurance reimbursement.

27. Federal Implementation of Revised Recommendations • CDC – October 2007 • Awarded $35 million to 23 jurisdictions to increase HIV testing opportunities for populations disproportionately affected by HIV, primarily African Americans, who are unaware of their HIV infection. Expected to test 1 million people and identify more than 20,000 new HIV infections. • SAMSHA – October 2007 • Awarded 67 grants totaling nearly $159 million over 5 years to provide coordinated substance abuse treatment and HIV/AIDS services targeting African American, Hispanic, and other racial or ethnic communities affected by epidemics of substance abuse and HIV/AIDS. • Office of Population Affairs – FY 2008 • Provided approximately $9.8 million for supplemental grants to expand the availability of onsite HIV testing, counseling, and related HIV referral services in Title X-funded service projects.

28. Full Endorsement • American College of Obstetricians and Gynecologists • AIDS Healthcare Foundation • American Academy of Pediatrics • American College of Nurse-Midwives • American College of Emergency Physicians • American College of Physicians • American Medical Association • Association of State and Territorial Health Officials • Emergency Nurses Association • HIV Medicine Association • National HIV/AIDS Clinicians' Consultation Center • National Medical Association

29. American Academy of Family Physicians American Academy of HIV Medicine Association of Nurses in AIDS Care The Kaiser Family Foundation National Alliance of State and Territorial AIDS Directors National Association of Community Health Centers National Association of County and City Health Officials National Association of People with AIDS National Association of Social Workers National Business Group on Health National Governors Association National Minority AIDS Council Partial Endorsement

30. National HIV/AIDS Partnerships (NHAP) • Focus: • Designed and implemented to prevent the spread of HIV through the collective resources and talents of leaders from a variety of sectors (i.e., health, business, labor, faith, sports, media, arts & entertainment, civic, social, and education organizations). • Framework: • Alliances: African Americans, Latinos, Native Americans, Business & Labor, Civic-Social, Health-care, and Faith. • Over 120 individuals and organizations joined NHAP alliances to use their influence to lead efforts in informing, educating, and encouraging HIV/AIDS prevention, testing, and treatment.

31. Goals of NHAP • Disseminating NHAP prevention messages regarding benefits of early HIV testing, prevention, and care; • Addressing the stigma associated with HIV/AIDS by promoting open dialogue about the disease, and support for those persons living with HIV and AIDS; • Developing the ability of partners to implement HIV prevention activities within their organization and communities; • Sustaining community awareness of the impact of HIV/AIDS within target populations and sectors.

32. NHAP Activities • Collaborate with Black AIDS Institute to seek and engage leadership of Historically Black Colleges and Universities to support campus-based HIV prevention policy, curricula, education/awareness programs, and health services at each school. • Coordinate educational and policy forums with faith leaders to raise awareness and increase skills in responding to HIV/AIDS within their churches, denominational conferences, seminars, and communities. • Coordinate a roundtable meeting for the spouses of faith leaders with the intent to encourage faith leaders to engage in discussions about the impact of the HIV/AIDS epidemic among African Americans and to encourage the implementation of actions and activities that will promote HIV/AIDS awareness and prevention.

33. New Program Announcements • Directly Funded Community-Based Organizations (CBOs) • Capacity Building Assistance • 5-year project periods • Awards expected to be made in FY 2009 • Consultations held in March 2008 with directly funded CBOs and health departments to obtain input in new capacity building assistance program announcement • Consultations for CBO program announcement planned in next 2 months to obtain information for new program announcement • Both programs reflect CDC’s continued commitment to reducing the burden of HIV among people of color who are disproportionately affected by the HIV/AIDS epidemic.

34. Programmatic and Scientific Priorities (2008-2010) - I • Reducing Disparities in HIV Incidence among African Americans, Hispanics, and MSM • Expand partnerships with other federal agencies, state and local health departments, academic institutions and CBOs to enhance research, policy, prevention services, testing, and linkage to care. • Continue implementation of Heightened National Response • Develop Hispanic/Latino Action Plan • Begin development and implementation of recommendations for MSM

35. Programmatic and Scientific Priorities (2008-2010) - II • Pre-Exposure Prophylaxis for HIV Prevention Trials and Recommendations • New biomedical intervention is needed for high-incidence populations. • Division is sponsoring 3 clinical trials of pre-exposure prophylaxis (PrEP) for HIV prevention among 3 populations at high risk for infection: heterosexuals in Botswana, intravenous drug users in Thailand, and MSM in the U.S. • All trials are designed to answer important questions about safety & efficacy of a tenofovir or tenofovir plus emtricitabine pill taken daily to prevent HIV infection. • Division plans to develop recommendations or guidelines based on clinical results.

36. Programmatic and Scientific Priorities (2008-2010) - III • Further Strengthen Ability to Monitor HIV Incidence, Resistance, Risk Behavior, and Delivery of Prevention Services • New systems to improve CDC’s ability to monitor HIV/AIDS epidemic. • Name-based HIV surveillance – All states, territories & District of Columbia have confidential name-based systems. Currently, 33 states have mature systems. • HIV incidence surveillance – First national estimates from HIV incidence system will be available in 2008.

37. Programmatic and Scientific Priorities (2008-2010) – III (cont.) • Medical Monitoring Project (MMP) and National HIV Behavioral Surveillance System (NHBS) – provide information on treatment and risk behavior. • MMP will be nationally representative, population-based surveillance system assessing clinical outcomes, behaviors, and quality of care among HIV-infected persons who are in medical care. • NHBS is a venue-based behavioral surveillance system that collects risk behavior data from 3 populations at high risk for acquiring HIV infection: MSM, IDUs, and high-risk heterosexuals. • Variant, Atypical and, Resistant HIV-1 Surveillance- HIV drug resistance surveillance – objectives are to incorporate surveillance of variant, atypical, and resistant HIV-1 into routine HIV surveillance activities; and estimate prevalence of mutations associated with HIV drug resistance, resistant patterns, and trends in dissemination of drug resistant strains; and determine prevalence of genetic subtypes.

38. Priority Recommendations/Guidelines • Revised Recommendations for HIV and STD Partner Services (published this year) • Revised Recommendations for HIV Testing in Non-Clinical Settings (published next year) • Guidelines for Testing in Correctional Settings • Interpretative Guidelines for Analyzing Western Blot Analyses • Recommendations for Elective Male Circumcision

39. Implementation of Section 2625, Early Diagnosis Program • Section 2625 of the Public Health Service Act, as amended by the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (RWHATMA), sets aside $30 million of CDC’s HIV prevention budget for grants to states that have certain policies for HIV testing • Provision 1: $20 million for States with policies in effect for both : • Voluntary opt-out testing of pregnant women and • Universal testing of newborns (within 48 hours of delivery) • Provision 2: $10 million for States with policies in effect for both: • Voluntary opt-out HIV testing in STD clinics and • Voluntary opt-out testing in substance abuse treatment centers • Applications due from state health departments by April 14 • Awards must be made May 31, 2008