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STAR Health Center, August 20, 2013

HIV Epidemiology And Prevention Jessica Yager, MD SUNY Downstate Medical Center Division of Infectious Diseases. STAR Health Center, August 20, 2013. Overview:. HIV natural history The Epidemiology of HIV: Global National Local Prevention Where do we go from here?.

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STAR Health Center, August 20, 2013

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  1. HIV Epidemiology And PreventionJessica Yager, MDSUNY Downstate Medical CenterDivision of Infectious Diseases STAR Health Center, August 20, 2013

  2. Overview: • HIV natural history • The Epidemiology of HIV: • Global • National • Local • Prevention • Where do we go from here?

  3. Natural history of HIV Infection

  4. Global estimates for adults and children, 2010 • People living with HIV34 million[31.6 – 35.2 million] • New HIV infections in 20102.7 million [2.4 – 2.9 million] • Deaths due to AIDS in 20101.8 million[1.6 – 1.9 million]

  5. HIV Infection: USA • Approximately 1,200,000 infected in US • Highest rates in MSM, IDUs, and their sexual partners • Approximately ¼ not aware of HIV status • HIV-2 rare • Approximately 55,000 new infections per year

  6. Demographic characteristics • 70% of new cases in racial ethnic minorities • Over 50% of new AIDS cases are in blacks • Over 30% of new AIDS cases are in women, almost 2/3 of whom are black • Nonetheless, dramatic reduction of children born with HIV infection

  7. Seroprevalence of HIV in MSM and IVDU populations

  8. HIV in New York City • 110,736 New Yorkers are known to be living with HIV or AIDS • 66,419 diagnosed with AIDS (15% of all U.S. cases) • 44,317 diagnosed with HIV (non-AIDS) • NYC has highest AIDS case rate in U.S. • 3x national average, 60x HP2010 target • More AIDS cases than Los Angeles, San Francisco, Miami & Washington DC combined • Estimated 20,000 more are HIV-positive, but do not know their status Data complete as of 12/31/10; www.nyc.gov/html/doh/html/dires/hivepi.shtml

  9. Transmission • Sexual • Perinatal • Transfusion • Occupational • Injection Drug use

  10. Sexual transmission • Worldwide epidemic driven by sexual transmission • HIV isolated from semen and vaginal secretions • Risk of transmission directly related to viral load and acute infections • Heterosexual transmission occurs more readily from male to female

  11. Sexual transmission risk (CDC)

  12. Conditions that may facilitate male to female HIV sexual transmission ConditionRelative Risk Oral contraceptives 2.5-4.5 Gonococcal cervicitis 1.8-4.5 Candida vaginitis 3.3-3.6 Genital ulcers 2.0-4.0 Vitamin A deficiency 2.6-12.9 CD4 count <200 6.1-17.6 CID 23:449, 1996; NEJM 336:1072, 1997; MMWR 47:RR-12, 1998; JID 177:167, 1998, JID 178:1053, 1998)

  13. Conditions that may facilitate female to male transmission ConditionRelative Risk Lack of circumcision 5.4-4.5 Genital ulcers 2.6-4.7 Sex during menses 3.4

  14. Perinatal transmission • 25% transmission rate in pre-AZT era • All children born to HIV infected women are antibody positive at birth • Breast feeding is proscribed in developing nations after birth • Combination of C-section and ART in women has reduced transmission to less than 3% • Transmission, if it occurs, typically occurs at birth

  15. Prevention • Behavior • Microbicide • Pre-exposure prophylaxis with ART • Male Circumcision • HSV-2 viral suppression • Vaccine • Expanded access to therapy

  16. 3 SEPTEMBER 2010 VOL 329 SCIENCE www.sciencemag.org

  17. Treatment as Prevention • Extensive biological plausibility • The concentration of HIV-1 in blood and genital tract correlates with sexual transmission • Antiretroviral agents that concentrate in the genital tract reduce HIV-1 viral load • Most observational reports indicate ART reduces transmission of HIV-1 in couples; August 2011 NEJM study correlating early treatment with reduced transmission

  18. HIV Rx “Cascade”Aspiration Meets Reality 80% 77% 66% 89% 77% Multiplies to 28% 850,000 HIV+ Americans (72%) lack viral control Refs: MMWR 2011; see also Gardner CID 2011; Burns CID 2010

  19. Back to Brooklyn… New HIV diagnoses by borough, 2002-2010: http://www.health.ny.gov/diseases/aids/statistics/epi/docs/2012_epidemiologic_profile.pdf

  20. Test and Treat:

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