Advancing HIV Prevention: New Strategies for a Changing Epidemic

1. 1 Advancing HIV Prevention: New Strategies for a Changing Epidemic Good morning/afternoon. My name is ______ and I am __________ from ___________ in the Division of HIV/AIDS Prevention at the CDC. Thank you for inviting me to talk with you today about CDC�s new Advancing HIV Prevention initiative, which we refer to as AHP. Good morning/afternoon. My name is ______ and I am __________ from ___________ in the Division of HIV/AIDS Prevention at the CDC. Thank you for inviting me to talk with you today about CDC�s new Advancing HIV Prevention initiative, which we refer to as AHP.

2. 2 Now I�d like to take a few minutes to talk about CDC�s initiative, Advancing HIV Prevention (AHP): New Strategies for a Changing EpidemicNow I�d like to take a few minutes to talk about CDC�s initiative, Advancing HIV Prevention (AHP): New Strategies for a Changing Epidemic

3. 3 Advancing HIV Prevention (AHP) What is the new initiative? Why a new initiative? What are the strategies? How does it impact/change our work in HIV prevention? This presentation will answer the following questions: What is AHP? Why a new HIV prevention initiative? What are the strategies of the AHP initiative? And how will the AHP initiative impact or change our HIV prevention work, both nationally and locally? This presentation will answer the following questions: What is AHP? Why a new HIV prevention initiative? What are the strategies of the AHP initiative? And how will the AHP initiative impact or change our HIV prevention work, both nationally and locally?

4. 4 What is the Initiative? Advancing HIV Prevention is aimed at reducing barriers to early diagnosis of HIV infection and increasing access to and utilization of quality medical care, treatment, and ongoing prevention services for those living with HIV Goal is to reduce HIV transmission A component of CDC�s overall prevention portfolio What is AHP? On April 17, 2003, CDC announced a new initiative called �Advancing HIV Prevention: New Strategies for a Changing Epidemic.� AHP is aimed at reducing barriers to early diagnosis of HIV infection and increasing access to quality medical care, treatment, and use of ongoing prevention services for people living with HIV. Our goal, as it has always been, is to decrease the number of new HIV infections in this country. AHP is one component of an overall HIV prevention portfolio What is AHP? On April 17, 2003, CDC announced a new initiative called �Advancing HIV Prevention: New Strategies for a Changing Epidemic.� AHP is aimed at reducing barriers to early diagnosis of HIV infection and increasing access to quality medical care, treatment, and use of ongoing prevention services for people living with HIV. Our goal, as it has always been, is to decrease the number of new HIV infections in this country. AHP is one component of an overall HIV prevention portfolio

5. 5 Why AHP Now? Stable morbidity and mortality Increasing number of persons living with HIV Concerns about possible increases in HIV incidence and syphilis, particularly among MSM Lack of knowledge of serostatus Effect of knowledge of serostatus on behavior Availability of a simple, rapid HIV test Why AHP now? There are many factors that caused the CDC to reassess and refocus some of its HIV prevention activities, including: Stable HIV-associated morbidity and mortality. AIDS cases decreased dramatically in the mid 1990s. However, the number of AIDS cases stabilized in 1998-2002. Due to effective treatments, the number of persons living with HIV that need care and prevention interventions has steadily increased. Concerns about possible increases in HIV incidence. After a decline in HIV incidence in the late 1980s and early 1990s, the number of new HIV infections stabilized at around 40,000 per year. Lack of knowledge of serostatus, in other words, not knowing that one is infected, can lead to HIV transmission. Encouraging people to get tested in a variety of settings along with working with health care providers to offer testing more routinely will help more people to know their serostatus. The effect of knowing one�s serostatus on sexual risk behavior. Research has shown that if an individual knows he or she is HIV positive, there is a reduction is risky sexual behaviors. Finally, the recent availability of a simple, rapid HIV test will allow us to take HIV testing and prevention out of the traditional medical setting and reach persons at risk who do not access care. The rapid HIV test will also combat the problem of people being tested but not returning for their results. Why AHP now? There are many factors that caused the CDC to reassess and refocus some of its HIV prevention activities, including: Stable HIV-associated morbidity and mortality. AIDS cases decreased dramatically in the mid 1990s. However, the number of AIDS cases stabilized in 1998-2002. Due to effective treatments, the number of persons living with HIV that need care and prevention interventions has steadily increased. Concerns about possible increases in HIV incidence. After a decline in HIV incidence in the late 1980s and early 1990s, the number of new HIV infections stabilized at around 40,000 per year. Lack of knowledge of serostatus, in other words, not knowing that one is infected, can lead to HIV transmission. Encouraging people to get tested in a variety of settings along with working with health care providers to offer testing more routinely will help more people to know their serostatus. The effect of knowing one�s serostatus on sexual risk behavior. Research has shown that if an individual knows he or she is HIV positive, there is a reduction is risky sexual behaviors. Finally, the recent availability of a simple, rapid HIV test will allow us to take HIV testing and prevention out of the traditional medical setting and reach persons at risk who do not access care. The rapid HIV test will also combat the problem of people being tested but not returning for their results.

6. 6 In the United States, the first cases of acquired immunodeficiency syndrome (AIDS) were reported in June 1981. The number of cases and deaths among persons with AIDS increased rapidly during the 1980s. During 1981-2001 an estimated 1.3-1.4 million people in the United States were infected with HIV. Between 1981-2002, there were 859,000 cases of AIDS and 487,672 deaths from AIDS reported to the CDC.In the United States, the first cases of acquired immunodeficiency syndrome (AIDS) were reported in June 1981. The number of cases and deaths among persons with AIDS increased rapidly during the 1980s. During 1981-2001 an estimated 1.3-1.4 million people in the United States were infected with HIV. Between 1981-2002, there were 859,000 cases of AIDS and 487,672 deaths from AIDS reported to the CDC.

7. 7 This slide shows the dramatic decrease in AIDS cases and AIDS deaths from 1981 to the early 1990s, as shown in the green and blue lines, respectively. During the late 1990s, after the introduction of combination antiretroviral therapy, the number of new AIDS cases and deaths declined substantially. From 1995-1998, the annual number of new AIDS cases declined 38%, but since 1998 the annual number of new AIDS cases and deaths has remained stable at approximately 40,000 and 16,000, respectively. As people with HIV and AIDS are living longer and healthier due to advances in treatment, the number of persons living with AIDS cases has steadily increased, as shown by the orange line. This slide shows the dramatic decrease in AIDS cases and AIDS deaths from 1981 to the early 1990s, as shown in the green and blue lines, respectively. During the late 1990s, after the introduction of combination antiretroviral therapy, the number of new AIDS cases and deaths declined substantially. From 1995-1998, the annual number of new AIDS cases declined 38%, but since 1998 the annual number of new AIDS cases and deaths has remained stable at approximately 40,000 and 16,000, respectively. As people with HIV and AIDS are living longer and healthier due to advances in treatment, the number of persons living with AIDS cases has steadily increased, as shown by the orange line.

8. 8 This slide shows trends and new data on the estimated number of HIV diagnoses by mode of exposure. They represent first-time HIV diagnoses, unlike the slide we just saw, which was of AIDS diagnoses. The data represent cases diagnosed from the 25 reporting states listed on the bottom of the slide. The solid line in the middle of each section represents the estimated diagnoses; lines on either side are the 95% confidence limits. For all groups, there was a decrease in or stable number of diagnoses through 1999. The concerning line on this graph is the one showing HIV diagnoses among men having sex with men (MSM), where you can see an increase from 1999 through 2002. Over this period, there was an 17% increase in MSM HIV diagnoses, which does not appear to be related to increases in HIV testing. This slide shows trends and new data on the estimated number of HIV diagnoses by mode of exposure. They represent first-time HIV diagnoses, unlike the slide we just saw, which was of AIDS diagnoses. The data represent cases diagnosed from the 25 reporting states listed on the bottom of the slide. The solid line in the middle of each section represents the estimated diagnoses; lines on either side are the 95% confidence limits. For all groups, there was a decrease in or stable number of diagnoses through 1999. The concerning line on this graph is the one showing HIV diagnoses among men having sex with men (MSM), where you can see an increase from 1999 through 2002. Over this period, there was an 17% increase in MSM HIV diagnoses, which does not appear to be related to increases in HIV testing.

9. 9 Awareness of Serostatus among Persons with HIV & Estimates of Transmission Currently, in the United States, there are an estimated 850,000-950,000 people who are infected with HIV. Of those, the majority of people, an estimated 670,000-770,000, or 75% are aware of their status. However, that leaves 25%, or 180,000 to 280,000 people, unaware that they are infected with HIV. It has been estimated that infections transmitted from this group account for 27,000, or 2/3, of the 40,000 new infections per year. The importance of getting these individuals tested and into treatment as well as offered prevention interventions is critical. Currently, in the United States, there are an estimated 850,000-950,000 people who are infected with HIV. Of those, the majority of people, an estimated 670,000-770,000, or 75% are aware of their status. However, that leaves 25%, or 180,000 to 280,000 people, unaware that they are infected with HIV. It has been estimated that infections transmitted from this group account for 27,000, or 2/3, of the 40,000 new infections per year. The importance of getting these individuals tested and into treatment as well as offered prevention interventions is critical.

10. 10 Late TestingSurveillance Data 1994-1999 104,780 persons diagnosed with HIV 43,089 (41%) developed AIDS within a year after HIV positive test Many HIV-infected people do not get tested until late in their infection. This slide shows data gathered during 1994-1999. Of the 104,780 people diagnosed with HIV during that time period, 41% of the people developed AIDS within one year after their first positive HIV test. With an average of 10 years between HIV infection and an AIDS diagnosis, these data suggest that many people are living with HIV for years before they are aware of their infection. Many HIV-infected people do not get tested until late in their infection. This slide shows data gathered during 1994-1999. Of the 104,780 people diagnosed with HIV during that time period, 41% of the people developed AIDS within one year after their first positive HIV test. With an average of 10 years between HIV infection and an AIDS diagnosis, these data suggest that many people are living with HIV for years before they are aware of their infection.

11. 11 CDC Funded HIV Testing2000 Number of tests approx. 2,000,000 New HIV diagnoses 18,000 % who didn�t return for results 31% CDC (unpublished) Many people who are tested for HIV do not return to learn their test results. Unpublished CDC data show that an estimated two million people took a CDC-funded HIV test in 2000. 18,000 of those represent new diagnoses (i.e., are not repeat tests on people who already know their status) and approximately 31% of those did not return to the site to learn their results. Use of a rapid HIV test, coupled with appropriate counseling, can help increase serostatus knowledge. Many people who are tested for HIV do not return to learn their test results. Unpublished CDC data show that an estimated two million people took a CDC-funded HIV test in 2000. 18,000 of those represent new diagnoses (i.e., are not repeat tests on people who already know their status) and approximately 31% of those did not return to the site to learn their results. Use of a rapid HIV test, coupled with appropriate counseling, can help increase serostatus knowledge.

12. 12 Proportion Reporting Anal Sex Behavior atSeroconversion & Post-Seroconversion Visits Data for this slide were gathered from a cohort study of high-risk gay men in seven cities. The first set of bars shows risk behavior prior to learning of HIV infection, with 39% of men reporting insertive unprotected anal intercourse and 47% reporting receptive unprotected anal intercourse. Three months after learning that they were infected with HIV, the percent reporting insertive unprotected anal intercourse dropped from 39% to 8% and those reporting receptive unprotected anal intercourse dropped from 47% to 12%. While these percentages rose slightly over the course of the year, a significant reduction in risk behavior was maintained for at least one year. These data suggest that simply knowing one is HIV-positive leads to safer sexual behavior. Data for this slide were gathered from a cohort study of high-risk gay men in seven cities. The first set of bars shows risk behavior prior to learning of HIV infection, with 39% of men reporting insertive unprotected anal intercourse and 47% reporting receptive unprotected anal intercourse. Three months after learning that they were infected with HIV, the percent reporting insertive unprotected anal intercourse dropped from 39% to 8% and those reporting receptive unprotected anal intercourse dropped from 47% to 12%. While these percentages rose slightly over the course of the year, a significant reduction in risk behavior was maintained for at least one year. These data suggest that simply knowing one is HIV-positive leads to safer sexual behavior.

13. 13 CDC�s Overall Approach to HIV Prevention CDC will continue to: Support efforts to keep negative people healthy Rely on behavioral prevention approaches Support voluntary testing Fund community-based organizations (CBOs) � especially those serving minorities Support community planning AHP important component of overall strategy.

14. 14 AHP Strategies Four priority strategies: Make voluntary HIV testing a routine part of medical care Implement new models for diagnosing HIV infections outside medical settings Prevent new infections by working with persons diagnosed with HIV and their partners Further decrease perinatal HIV transmission The primary goal of the new initiative � to reduce HIV transmission � is not new. AHP emphasizes the use of proven public health approaches to reduce incidence and the spread of disease. The initiative consists of four priority strategies: Make voluntary testing a routine part of medical care. Implement new models for diagnosing HIV infections outside medical settings. Prevent new infections by working with persons diagnosed with HIV. Further decrease perinatal HIV transmission. The primary goal of the new initiative � to reduce HIV transmission � is not new. AHP emphasizes the use of proven public health approaches to reduce incidence and the spread of disease. The initiative consists of four priority strategies: Make voluntary testing a routine part of medical care. Implement new models for diagnosing HIV infections outside medical settings. Prevent new infections by working with persons diagnosed with HIV. Further decrease perinatal HIV transmission.

15. 15 Impact and Outcomes of AHP Expand efforts to help PLWH to learn their HIV serostatus Expand CDC�s efforts in focusing prevention programs for PLWH Focus CBO and HD prevention activities to ensure that every person living with HIV has: The opportunity to get tested Access to state of the art medical care, and Access to ongoing prevention services to prevent HIV/STD transmission to partners Decrease new HIV infections and STD transmission What is the desired impact and outcomes of the Advancing HIV Prevention Initiative? As stated earlier in the presentation, stable HIV-associated morbidity and mortality, concerns about increases in HIV incidence, and the recent availability of a simple, rapid HIV test combined with strong prevention collaborations among communities heavily affected by HIV support the need to reassess and refocus some of CDC's HIV-prevention activities. An emphasis on greater access to testing and on providing prevention and care services for persons infected with HIV can reduce new infections and lead to reductions in HIV-associated morbidity and mortality. In addition, simplifying prenatal and other testing procedures can lead to more effective use of resources that CDC provides to prevent perinatal and other HIV transmission. Through �Advancing HIV Prevention: New Strategies for a Changing Epidemic,� CDC expects to expand efforts to help people living with HIV learn their serostatus. The initiative also has the goals that every HIV-infected person will have the opportunity to be tested and have access to state-of-the-art medical care and to the prevention services needed to prevent HIV transmission. What is the desired impact and outcomes of the Advancing HIV Prevention Initiative? As stated earlier in the presentation, stable HIV-associated morbidity and mortality, concerns about increases in HIV incidence, and the recent availability of a simple, rapid HIV test combined with strong prevention collaborations among communities heavily affected by HIV support the need to reassess and refocus some of CDC's HIV-prevention activities. An emphasis on greater access to testing and on providing prevention and care services for persons infected with HIV can reduce new infections and lead to reductions in HIV-associated morbidity and mortality. In addition, simplifying prenatal and other testing procedures can lead to more effective use of resources that CDC provides to prevent perinatal and other HIV transmission. Through �Advancing HIV Prevention: New Strategies for a Changing Epidemic,� CDC expects to expand efforts to help people living with HIV learn their serostatus. The initiative also has the goals that every HIV-infected person will have the opportunity to be tested and have access to state-of-the-art medical care and to the prevention services needed to prevent HIV transmission.

16. 16 Additional Information on AHP www.cdc.gov/hiv/partners/ahp.htm CDC. Advancing HIV prevention: New strategies for a changing epidemic. MMWR 2003;52:329-332 A section on the CDC�s website is devoted to AHP. <www.cdc.gov/hiv/partners/ahp.htm> Here you can find the latest materials and references on AHP. A section on the CDC�s website is devoted to AHP. <www.cdc.gov/hiv/partners/ahp.htm> Here you can find the latest materials and references on AHP.

17. 17 Contact Information Sean David Griffiths, M.P.H Coordinator, Advancing HIV Prevention Initiative (AHP) Divisions of HIV/AIDS Prevention 1600 Clifton Rd, NE MS E-35 Atlanta, GA 30333 SGriffiths@cdc.gov 404.639.3453