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Christiansted St. Croix, USVI The American Paradise

Christiansted St. Croix, USVI The American Paradise. NOT YOUR OLD HIV. The changing patterns of HIV epidemiology in the United States Deborah Ellis, PhD, MS, MSPH, MLS(ASCP), CIC. Incidence vs. Prevalence.

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Christiansted St. Croix, USVI The American Paradise

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  1. Christiansted St. Croix, USVIThe American Paradise

  2. NOT YOUR OLD HIV The changing patterns of HIV epidemiology in the United States Deborah Ellis, PhD, MS, MSPH, MLS(ASCP), CIC

  3. Incidence vs. Prevalence • Incidence Rate - Number of new disease cases per population at risk. Tells you how many new infections are occurring. The incidence rate of a disease is used to determine trends. • Prevalence Rate – Number of existing cases per population at risk at a designated time. Tells you the overall amount of disease in the community.

  4. Question • How many new HIV infections were diagnosed in the US in 2010? • 10,000 • 50,000 • 100,000 • 1,000,000

  5. Answer • Approximately 50,000 people become infected each year. • Since the height of the epidemic in the mid-1980s • Decreased from 13,000 to 50,000

  6. Question • Is the number of New HIV infections in the United States………………? • Increasing • Decreasing • Stable

  7. Answer • Rate of new infections stable since the mid-1990s. • However, continued growth in the number of people living with HIV ultimately may lead to more new infections IF prevention, care, and treatment efforts are not targeted to those at greatest risk.

  8. What we know about HIV • What we know – • First cases appeared in June 1981 • Case definition developed 1993 • The HIV/AIDS epidemic has evolved to become the greatest challenge in global health today • ~ 34 million persons living with HIV worldwide as of 2012.

  9. Infectious Agent • What we know – • A Lentivirus – slow replicating retrovirus • Does not survive long outside the body • HIV-1 Nearly all HIV cases in the US • HIV-2 Identified in West Africa, 1987 mostly in Sub-Saharan Africa

  10. Risk Factors • We know that certain behaviors increases risk for HIV infection • men having sex with other men (MSM) • injected drug abuse • engaging in unprotected heterosexual sex • babies born to women with HIV

  11. Risk Factors • Blood • Semen • pre-seminal fluid • rectal fluids • vaginal fluids • breast milk—from an HIV-infected person can transmit HIV

  12. Testing • Getting tested for HIV remains the only way to know if you have HIV infection • Antibody detection-immunoassay screening • RNA – detects the virus

  13. States with highest Prevalence Top 10 states

  14. Cities with highestPrevalence

  15. HIV AIDS = 

  16. Shifting Patterns • There seems to have been a shift in the HIV epidemic from mostly infection through homosexual contact to infection through heterosexual. • The number of new HIV infections in the U.S. has remained relatively constant. • about 50,000 a year since 1998 • "slow but steady increase" in the number of gay black men and heterosexual black women who are contracting the disease.

  17. By Gender/Race Ethnicity

  18. By Ethnicity • New HIV Infection by Ethnicity 2009 • African American 42% • Caucasians 36% • Hispanic/Latino 19% • Others 3% • New HIV Infection by Ethnicity 2011 • African Americans 54% • Caucasians 26% • Hispanic/Latinos 19% • Others 1%

  19. Question • How many women age 55-74 reported having sex in the past 12 months? • 10% • 20% • 50% • OMG! My grandmother has sex?

  20. By Age • 50% of women aged 55-74 surveyed reported engaging in sex in the past 12 months. • (WHAT!!! That’s ALL?) I have no idea who they surveyed.

  21. By Age • No longer a disease of young people • Older persons living with HIV • 50 and older accounted for 19% of the estimated 1.1 million • 50 and older have many of the same HIV risk factors as younger Americans.

  22. HIV infection by Age Here is how the 19% breaks down

  23. HIV infection by Age Older Americans are more likely than younger Americans to be diagnosed with HIV infection later in the course of their disease.

  24. What is the major contributing factor for this shift?

  25. Advent of Treatment • Before 1996 – Non-standard, research and experimental treatment options. • In 1996 - Advent of Antiretroviral Therapy • Recommendations published by the CDC

  26. Treatment Highly Active Antiretroviral Therapy HAART • Attack virus at different stages of HIV life cycle and different targets • Maintains function of the immune system • Prevents opportunistic infections

  27. Treatment • Effective in suppressing systemic HIV viral load. • HAART has dramatically reduced HIV-associated morbidity and mortality

  28. Chronic Manageable Condition HIV no longer leads to a fatal disease Increased life expectancy Significant improvement in health outcomes Chronic manageable condition

  29. Treatment Recommendations • HAART is now recommended for ALL HIV infected individuals • HAART treatment options recommended as part of post-exposure prophylaxis.

  30. Testing • Better testing for detection and monitoring • Antibody screening • Western-blot • RNA – PCR • CD4 counts • Viral Load • Testing has increased specificity and sensitivity • Earlier detection window 3-6 months • Better access to testing

  31. So Then Why? • What explains continued HIV incidence in the face of effective HIV treatment and better testing? • Late Diagnosis • Linkage to care for positive individuals • Retention in care over time • Maintaining Viral Suppression • Risk Compensation • STI co-infections • Advancing Age – immune response to treatment • Ethnicity

  32. Late Diagnosis • Late diagnosis is a serious obstacle to HIV prevention efforts in all subpopulations, contributing to the continuing spread of HIV by those who do not know they are infected. • ~25% undiagnosed – half of new HIV infections

  33. Late Diagnosis • Late-testers • Younger (18-29) • Heterosexual • Less educated • African-American/Hispanic • Knowledge of one’s infection also reduces the risk of transmission

  34. Virally Suppressed

  35. Least likely to be retained in care

  36. Risk Compensation • Risk compensation – Achilles' Heel • becoming more careful where they sense greater risk and less careful if they feel more protected • ↓ Viral load ► ↓ infectivity = perceived reduced risk of HIV infection ↑ at risk sexual behavior

  37. Sexually Transmitted Co-Infections • HIV - STI co-infections • Chlamydia, Gonorrhea and Syphilis, Hep B and Hep C • STD ↔ HIV • Shedding in genital tract • Increases HIV shedding and infectiousness

  38. Age • Advancing Age- • Younger persons (≤50) respond better to HAART • Management of comorbidities such as • Lipid-level abnormalities • Diabetes • Hypertension • Increase adherence – proper regimen selection

  39. Shifting Patterns

  40. How do we prevent new Infections? • Getting to Zero • Primary care ↔specialty care • HIV testing – routine testing • HAART Adherence counseling at each visit • Risk Reduction Counseling – Secondary prevention • Behavioral interventions – still effective

  41. Getting to Zero • Aggressively recruit patients • Monitor and intervene for optimal adherence. • Educate about the realities of infectiousness. • Counsel against risk compensation. • Aggressively control STI

  42. Getting to Zero • National HIV/AIDS Strategy with three primary goals: • reducing the number of people who become infected with HIV • increasing access to care and optimizing health outcomes for people living with HIV, and • reducing HIV-related health disparitiesamong ethnic groups by identify those populations most affected and most at risk for HIV infection.

  43. Getting to Zero • Add to focus, heterosexual females • Behavior interventions and Social interventions • Become aware of partners risk factors • Condoms • IDU – Trade sex for drugs • Sexual abuse – likely to have multiple partners • Address physical abuse • Focus on Hispanic and African American Communities

  44. Getting to Zero in Nevada • GOAL ONE • Increase the number of people receiving HIV prevention awareness and education messages throughout Nevada, with a special emphasis on identified target populations. • GOAL TWO • Increase the number of people receiving HIV testing services throughout Nevada, with a special emphasis on identified target populations. • GOAL THREE • Increase the community capacity to provide referrals, supportive services, and linkages to care to those community

  45. Questions?

  46. References Holmes KK , Center for AIDS and Sexually Transmitted Diseases, University of Washington School of Medicine, Seattle. HIV InSite Knowledge Base Chapter, March 2003 transparent image Dennis H. Osmond, PhD, University of California San Francisco http://hivinsite.ucsf.edu/InSite?page=kb-01-03#S2.4X Hospital Practice (Office Ed.) [1991, 26(11):153-7, 161, 165 passim] Centers for Disease Control and Prevention (CDC) HIV among Older Americans, http://www.cdc.gov/hiv/risk/age/olderamericans/ Downloaded from http://aidsinfo.nih.gov/guidelines on 3/24/2014 Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescent. Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival. N Engl J Med . 1996;334(11):701-706. Available at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8594430

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