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Status of the U.S. HIV/AIDS Epidemic: Is it changing, and if not, why not?

Status of the U.S. HIV/AIDS Epidemic: Is it changing, and if not, why not?. Harold W. Jaffe, M.D. Department of Public Health University of Oxford. HIV/AIDS in the United States. What is the magnitude of the epidemic? What interventions prevent HIV transmission? What needs to be done?.

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Status of the U.S. HIV/AIDS Epidemic: Is it changing, and if not, why not?

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  1. Status of the U.S. HIV/AIDS Epidemic: Is it changing, and if not, why not? Harold W. Jaffe, M.D. Department of Public Health University of Oxford

  2. HIV/AIDS in the United States • What is the magnitude of the epidemic? • What interventions prevent HIV transmission? • What needs to be done?

  3. Cases Deaths Adults/Adolescents 979,287 545,529 9,089 4,865 Children (<13 years) 988,376 550,394 Total AIDS Cases and Deaths Reported 1981 – 2005, United States

  4. Estimated numbers of AIDS cases by year of diagnosis United States, 2001-5

  5. Estimated Number of Adults and Adolescents Living with HIV/AIDS, by Sex, 33 States, 2001-5 400 350 Males 300 250 No. of persons (in thousands) 200 Females 150 100 50 0 2001 2002 2003 2004 2005 Year

  6. Proportion of HIV/AIDS Cases among Adults and Adolescents, by Transmission Category 33 States, 2001-5 55 Male-to-male sexual contact 50 45 40 High-risk heterosexual contact* 35 Cases, % 30 25 Injection drug use (IDU) 20 15 10 Male-to-male sexual contact and IDU 5 0 2001 2002 2004 2005 2003 Year of diagnosis

  7. Proportion of HIV/AIDS Cases among Adults and Adolescents, by Race/Ethnicity, 33 States, 2001-5 60 Black, not Hispanic 50 40 White, not Hispanic Cases, % 30 Hispanic 20 American Indian/ 10 Asian/Pacific Islander Alaska Native 0 2001 2002 2003 2004 2005 Year of diagnosis

  8. 180 ) 0 0 0 160 1 x ( s 140 n o i t c 120 e f n I l a 100 u n n A 80 f o r e 60 b m u 40 N d e t 20 a m i t s 0 E Estimated Number of New HIV Infections Annually, United States R. Brookmeyer. Science 1991; 253:37

  9. Current Status of National HIV Incidence Surveillance WA CHI MA NYS CT MI NYC PA SF OH Phil IN NJ CO IL MD CA MO VA DC NC OK TN AZ LA Cty SC GA MS AL LA TX FL HOU PR

  10. HIV-1 Capture EIA (BED)* • Captures both HIV and non-HIV IgG antibodies • Proportion of HIV antibodies increases with duration of infection • Low proportion generally indicates recent infection *Uses synthetic peptides that represent B,E, and D subtypes

  11. National HIV Behavioral Surveillance (NHBS) • Rotating annual cycles of surveillance in MSM, IDU, and heterosexuals in high-prevalence areas • Face-to face interviews on risk behaviors, HIV testing, and use of prevention programs • Minimum of 500 eligible persons from each participating area

  12. NHBS in MSM • Venue-based sample of 10,030 men in 15 U.S. cities, Nov 2003-April 2005 • 47% of participants reported unprotected anal sex with male partner in last 12 mo. • Approx 11% of HIV-negative men reported unprotected anal sex with partner of unknown infection status at most recent sexual encounter MMWR 2006;55:SS-6

  13. New Test Implementation and Declining Risk of Viral Infections from Transfusion M P Bush, et al. JAMA 2003; 289:959

  14. Estimated numbers of AIDS cases in children <13 years of age, by year of diagnosis, United States, 1992-2005,

  15. Risk Factors for Transmission after Percutaneous Exposure to HIV-Infected Blood Adjusted odds Risk Factor ratio (95% CI) Deep injury 15 (6.0-41) Blood on device 6.2 (2.2-21) Needle in blood vessel 4.3 (1.7-12) Terminal illness in source 5.6 (2.0-16) PEP with AZT 0.19 (0.06-0.52) DM Cardo, et al. N Engl J Med 1997;337:1485

  16. Condoms “ (Male) latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV” CDC. Fact Sheet for Public Health Personnel. Male Latex Condoms and Sexually Transmitted Diseases

  17. Incident HPV after first intercourse and condom use by male partner,82 U.S. female college students Frequency condom use Adjusted hazard P-value ratio (95% CI) <5% 1.0 5-49% 1.0 (0.5-1.8) 0.92 50-99% 0.5 (0.3-0.9) 0.02 100% 0.3 (0.1-0.6) 0.003 RL Winer, et al. N Engl J Med 2006;354:2645

  18. Impact of Male Circumcision on Female-to-Male HIV Transmission 1B Auvert, et al. PLoS Medicine 2005;2:e298 2NIAID Press Release, Dec 13, 2006

  19. Systematic Review of HIV Behavioral Interventions, U.S., 2000-2004 • 18 “best evidence” interventions identified from 100 unique studies • Target populations include MSM, high-risk adults and youth, IDUs, HIV+ persons • Significant effects included reduced unprotected sex or STDs from 3-12 mo. after intervention • HIV incidence not an endpoint CM Lyles, et al. Am J Public Health 2007;97:133

  20. Behavior Change following HIV Diagnosis, United States • Meta-analysis of sexual behavior before and after HIV diagnosis • Effect measured by self-reports of unprotected anal or vaginal intercourse, adjusted to include only “at-risk” partners • Model of data from 5 studies indicates average risk reduction of 64% (57-71%) G Marks, et al. JAIDS 2005;39:446

  21. What might work to prevent HIV transmission? • Vaccines • Topical microbicides • Cervical barriers (diaphragms and caps) • Pre-exposure prophylaxis • Treatment to reduce infectivity • Prevention of HSV-2 infection

  22. Needle and Syringe Exchange “Moderate evidence indicates that multi component HIV prevention programs that include needle and syringe exchange reduce intermediate HIV risk behavior. However, evidence regarding the effect of needle and syringe exchange on HIV incidence is limited and inconclusive.” Institute of Medicine. Preventing HIV infection among injecting drug users in high risk countries: An assessment of the evidence. (2006)

  23. Cochrane Review of Abstinence-only Programs for HIV Prevention • Eight published RCTs; all involve U.S. youth (N=13,191) • Programs based in schools (6), home (1) and community (1) • Median follow-up of 12 months • No significant risk reduction indicated by self-reported behavioral or biological outcomes K Underhill, et al. Cochrane Database of Systematic Reviews (in press)

  24. An Abstinence-only Intervention forYoung Adolescents • RCT of 4 interventions in 662 African-American adolescents ages 10-15 • Endpoint of self-reported sexual activity over 24 months • Significantly less sexual activity reported in abstinence-only (AO) group • However, ~30% of virgins in AO group became sexually active during follow-up JB Jemmott, et al. Abstract MOAX0504, Toronto International AIDS Conference, 2006

  25. “AIDS is a war against humanity” Nelson Mandela Barcelona, 2002

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