HIV/AIDS and Public Health

1. HIV/AIDS and Public Health Karina Danvers Director, CT-LPS New England AIDS Education and Training Center Yale AIDS Program Yale School of Medicine

2. HIV/AIDS • AIDS (Acquired immune deficiency syndrome or acquired immunodeficiency syndrome) is a disease caused by a virus called HIV (Human Immunodeficiency Virus). The illness alters the immune system, making people much more vulnerable to infections and diseases. This susceptibility worsens as the disease progresses. • HIV is found in the body fluids of an infected person (semen and vaginal fluids, blood and breast milk). The virus is passed from one person to another through blood-to-blood and sexual contact. In addition, infected pregnant women can pass HIV to their babies during pregnancy, delivering the baby during childbirth, and through breast feeding. • HIV can be transmitted in many ways, such as vaginal, oral sex, anal sex, blood transfusion, and contaminated hypodermic needles. • **There is currently no cure for HIV/AIDS. http://www.nlm.nih.gov/medlineplus/ency/article/000594.htm

3. Public Health • Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals. • The population in question can be as small as a handful of people, or as large as all the inhabitants of several continents. • The dimensions of health can encompass "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", as defined by the United Nations' World Health Organization. Stigma. • Public health incorporates the interdisciplinary approaches of epidemiology, biostatistics and health services. Environmental health, community health, behavioral health, health economics, public policy, insurance medicine and occupational health (respectively occupational medicine) are other important subfields. • Promotion of hand washing and breastfeeding, delivery of vaccinations, and distribution of condoms to control the spread of sexually transmitted diseases are examples of common public health measures. • Modern public health practice requires multidisciplinary teams of professionals including physicians specializing in public health/community medicine/infectious disease, epidemiologists, biostatisticians, public health nurses, and others. Winslow, Charles-Edward Amory (1920 Jan 9). "The Untiltled Fields of Public Health". Science51 (1306): 23–33.

4. HIV/AIDS Social Determinants • “The social determinants of health are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.” • Poverty WHO Commission on the Social Determinants of Health, 2008

5. Public Health Response in the United States Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal www.ias.org/2013

6. The first time we heard GRID? 1980 • On June 5, the U.S. Centers for Disease Control and Prevention (CDC) publish a Morbidity and Mortality Weekly Report (MMWR), describing cases of a rare lung infection, Pneumocystiscarinii pneumonia (PCP), in five young, previously healthy, gay men in Los Angeles. • All the men have other unusual infections as well, indicating that their immune systems are not working; two have already died by the time the report is published. • This edition of the MMWR marks the first official reporting of what will become known as the AIDS epidemic. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal www.cdc.gov

7. Public Health Response: 1981 • In September, Congressional representatives Henry Waxman and Phillip Burton introduce legislation to allocate $5 million to CDC for surveillance and $10 million to the National Institutes of Health (NIH) for AIDS research. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.aids.gov/pdf/aidsgov-timeline.pdf

8. Public Health Response: 1983 • The U.S. Centers for Disease Control and Prevention (CDC) establish the National AIDS Hotline to respond to public inquiries about the disease. • On January 4, CDC hosts a national conference to determine blood bank policy blood for testing blood for HIV, but participants fail to reach consensus on appropriate action. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.aids.gov/pdf/aidsgov-timeline.pdf

9. PLWA Response: 1983 • In June, people living with AIDS (PLWAs) take over the plenary stage at the Second National AIDS Forum in Denver, and issue a statement on the right of PLWAs to be at the table when policy is made, to be treated with dignity, and to be called “people with AIDS,” not “AIDS victims.” • The statement becomes known as “The Denver Principles,” and it serves as the charter for the founding of the National Association of People with AIDS (NAPWA). Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.aids.gov/pdf/aidsgov-timeline.pdf

10. Red Ribbon/World AIDS Day • The Red Ribbon should be used as a consciousness raising symbol -- connection to blood and the idea of passion -- not only anger, but love, like a valentine.“ • First worn publicly by Jeremy Irons at the 1991 Tony Awards.

11. Universal Precautions • The practice was introduced in 1985–88. In 1987, the practice of universal precautions was adjusted by a set of rules known as body substance isolation. • In 1996, both practices were replaced by the latest approach known as standard precautions (health care). • Health professionals are instead making judgments based on an individual's health status.It is speculated that this differential approach to care stems from stigma towards HIV and hepatitis C, rooted largely in fears and misconceptions around transmission and assumptions about patient lifestyle and risk. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal

12. Bathhouses in San Francisco • The San Francisco bathhouse battles of 1984: civil liberties, AIDS risk, and shifts in health policy. • In the mid-1980s, controversy emerged in a number of American cities over the roles gay bathhouses and sex clubs might play in the spread of AIDS, and in raising safe-sex awareness. In 1984, San Francisco became the first city where political debates broke out over AIDS-related policies for bathhouses and sex clubs. • These debates were dominated by questions of public health and gay civil liberties. • A variety of proposals were put forward during 1984 to try to reconcile these two concerns, or to give one a higher priority than the other. Certain officials in San Francisco's government, and members of its gay/lesbian/bisexual community, strongly disagreed over whether the businesses should be closed, should make their own AIDS-prevention efforts, or should continue operating under new regulations. Policies implemented for the city's baths were disconnected from the known AIDS risk of different sexual behaviors, and from research findings on AIDS and the local baths. Political and judicial decisions concerning San Francisco's bathhouses and sex clubs that were made in 1984 had continuing influences on these businesses through the later 1980s and the 1990s. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal

13. Public Health Response: 1986 • The National Academy of Sciences issues a report critical of the U.S. response to a “national health crisis.” • The report calls for a U.S. $2 billion investment. • An Institute of Medicine report calls for a national education campaign and for creating a National Commission on AIDS. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.aids.gov/pdf/aidsgov-timeline.pdf

14. Public Health Response: 1987 • CDC launches the first AIDS-related public service announcements, “America Responds to AIDS.” • The America Responds to AIDS campaign presented a diverse group of people addressing a litany of questions about AIDS. The questions used an unidentified interviewer to present these fictional conversations, all of which involved women in this case, as happening all over America. The posters did not include any actual information on prevention or testing, the campaign encouraged a dialogue about AIDS among peers that diffused some of the shame and anxiety associated with the disease. In this way, the campaign combated AIDS by first addressing the fear. http://www.aids.gov/pdf/aidsgov-timeline.pdf

15. America Responds to AIDS http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1580340/

16. Needle Exchange 1988 • In April, the first comprehensive needle-exchange program (NEP) in North America is established in Tacoma, WA. San Francisco then establishes what becomes the largest NEP in the nation. • State-established Needle Exchange programs currently operate in California, Colorado, Connecticut, Illinois, Maryland Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, Washington and Wisconsin. Each of these 13 states has passed laws exempting program participants from criminal liability for carrying hypodermic syringes. • So why has it not been possible to achieve federal funding for such programs from 1988 to the present? • On April 20, Donna Shalala, Secretary of the U.S. Department of Health and Human Services, determines that needle-exchange programs (NEPs) are effective and do not encourage the use of illegal drugs, but the Clinton Administration does not lift the ban on use of Federal funds for NEPs. • The American Medical Association (AMA), the American Nurses Association, the American Public Health Association (APHA), the American Society of Addiction Medicine, the American Bar Association, and the Society of Christian Ethics, to name a few, all endorse needle exchange programs. http://www.aids.gov/pdf/aidsgov-timeline.pdf

17. First of Its Kind: 1988 • On May 26, the U.S. Surgeon General, C. Everett Koop, launches the U.S.’s first coordinated HIV/AIDS education campaign by mailing 107 million copies of a booklet, Understanding AIDS to all American households. http://www.aids.gov/pdf/aidsgov-timeline.pdf

18. Ryan White ACT: 1990 • In August, the U.S. Congress enacts the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990, which provides $220.5 million in Federal funds for HIV community-based care and treatment services in its first year. • The U.S. Health Resources and Services Administration (HRSA) manages the program, which is the nation’s largest HIV-specific Federal grant program. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.aids.gov/pdf/aidsgov-timeline.pdf

19. Ryan White • Ryan Wayne White was an American teenager from Kokomo, Indiana, who became a national poster child for HIV/AIDS in the United States, after being expelled from middle school because of his infection. http://www.aids.gov/pdf/aidsgov-timeline.pdf

20. Innovations: 1990 • CDC adopts the HIV-prevention counseling model, a “client-centered” approach that focuses on the patient, rather than the disease. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.aids.gov/pdf/aidsgov-timeline.pdf

21. Magic Johnson 1991 www.oprahwinfreyshow.com

22. Interdisciplinary approaches: 1991 • The U.S. Congress enacts the Housing Opportunities for People with AIDS (HOPWA) Act of 1991. Administered by the U.S. Department of Housing and Urban Development (HUD), HOPWA grants to states and local communities provide housing assistance to people living with AIDS. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.aids.gov/pdf/aidsgov-timeline.pdf

23. New Tools: 1993 • On May 7, the U.S. • Food and Drug Administration (FDA) approves the female condom. http://www.aids.gov/pdf/aidsgov-timeline.pdf

24. Pregnancy • The U.S. Public Health Service recommends that pregnant women be given the antiretroviral drug AZT to reduce the risk of perinatal transmission of HIV. (ACTG 076). • 2002: State-mandated HIV testing in Connecticut for pregnant women.** • **GYN must offer the test • **Women may refuse … • **New born tested after delivery http://www.aids.gov/pdf/aidsgov-timeline.pdf

25. Estimated Numbers of Perinatally Acquired AIDS Cases by Year of Diagnosis, 1985–2010 — United States and Dependent Areas 8 Note: Data have been adjusted for reporting delays and missing risk-factor information. www.cdc.gov

26. Minority Epidemic • The U.S. Centers for Disease Control and Prevention (CDC) report that African Americans account for 49% of U.S. AIDS-related deaths. • AIDS-related mortality for African Americans is almost 10 times that of Whites and three times that of Hispanics. http://www.cdc.gov/hiv/risk/racialethnic/aa/

27. Latinos: 1999 • The Congressional Hispanic Caucus, with the Congressional Hispanic Caucus Institute , convenes Congressional hearings on the impact of HIV/AIDS on the Latino community. Inter-governmental, Regional, Global Society Community, Organizations Relationships, Social Groups/Networks Macro,Distal Individual Micro, Proximal http://www.cdc.gov/hiv/risk/racialethnic/aa/

28. New HIV Infections: United States

29. Hispanic Americans • Hispanic Americans accounted for 20% of all HIV infection cases in 2011. • Hispanic males are 3 times as likely to have either HIV infection or AIDS as compared to white males. • Hispanic females are 4 times as likely to have AIDS in 2011 as White females. • Hispanic men are 2.5 times as likely as non-Hispanic White men to die of HIV/AIDS. • Hispanic women are twice as likely as non-Hispanic white women to die of HIV. • In 2011, Hispanic females were 4 times more likely to be diagnosed with HIV infection, as compared to White females. http://minorityhealth.hhs.gov/templates/content.aspx?ID=3327

30. CT DPH, Epidemiologic Profile of HIV in CT 2013

34. CT Public Act No. 09-133 Effective July 1, 2009 • An Act Concerning Revisions to the HIV Testing Consent Law • Eliminates requirement for separate consent • Allows general consent for performance of medical procedures • Eliminates the requirement for extensive pre-test counseling

35. Courtesy of D. Villanueva, 2013

36. http://minorityhealth.hhs.gov/templates/content.aspx?ID=3327

37. Testing Increasing Efforts http://www.orasure.com/

38. Adherence • While the ultimate goal of ART is to reduce HIV-related morbidity and mortality, the initial goal is full and durable viral suppression. • Full viral suppression allows for maximal reconstitution or maintenance of immune function and minimizes the emergence of drug-resistant virus selected by ongoing replication in the presence of antiretroviral drugs. • Many have viewed nonadherence as a significant public health concern based on the expectation that nonadherence would speed the development and transmission of drug-resistant virus. HIV InSite Knowledge Base ChapterMay 2005; Content reviewed January 2006

39. Community Viral Load • Community viral load, defined as an aggregation of individual viral loads of people infected with HIV in a specific community, has been proposed as a useful measure to monitor HIV treatment uptake and quantify its effect on transmission. • Lancet Infect Dis. 2013 May;13(5):459-64. doi: 10.1016/S1473-3099(12)70314-6. Epub 2013 Mar 25. • In San Francisco, reductions in community viral load have even been associated with decreases in newly diagnosed and reported HIV infections. Public health leaders at the CDC and elsewhere are working to improve the capacity of state and local health departments to be able to monitor this increasingly useful population measure. – • http://blog.aids.gov/2011/03/community-viral-load-a-new-way-to-measure-our-progress.html#sthash.U9NHRFVu.dpuf

40. Functional Cure • The definition of a "functional HIV cure“ means: • undetectable viremia without ART • no disease progression • no CD4 loss • lack of HIV transmission • Universal access to cART must remain a top priority. • CADAP: CT AIDS Drug Assistance Program http://iasociety.org/Web/WebContent/File/HIV_Cure_Churchill_Canberra_Presentation.pdf

41. Medical Interventions: 2006 • In December, a University of Illinois at Chicago study indicates that medical circumcision of men reduces their risk of acquiring HIV during heterosexual intercourse by 53 percent. The clinical trial of Kenyan men is supported by the U.S. National Institute for Allergy and Infectious Diseases and the Canadian Institute of Health Research. http://www.aids.gov/pdf/aidsgov-timeline.pdf

42. HIV Pre-exposure (PrEP) • PrEP is short for Pre-Exposure Prophylaxis. It is a new HIV prevention method in which people who do not have HIV take a daily pill to reduce their risk of becoming infected. www.aids.gov

43. Post-exposure Prophylaxis (PEP) • Post-exposure prophylaxis is antiretroviral drug treatment that is started immediately after someone is exposed to HIV. The aim is to allow a person’s immune system a chance to provide protection against the virus and to prevent HIV from becoming established in someone’s body. • It usually consists of a month long course of two or three different types of the antiretroviral drugs that are also prescribed as treatment for people living with HIV. www.aids.gov

44. Stigma 2013 • Stigma • Internal • External • Partner Services in CT

45. STD Connecticut Partner Notification Services • The State of Connecticut, Department of Public Health, STD Control Program attempts to interview all patients with syphilis. Some patients with gonorrhea, Chlamydia, and HIV are interviewed to assist with partner notification. • Patients are educated about their infection, counseled on how to avoid re-infection, and asked to confidentially provide the names and locating information of their sexual partners • Partners are confidentially located for screening and treatment by trained field staff without divulging the identity of the infected patient. • MMWR - November 7, 2008 / Vol. 57/ No. RR-9 • "Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection” www.ct.gov/dph/cwp/view.asp?a=3136&q=416218‎

46. Criminalization of HIV • Is HIV Criminalization Is Bad Public Policy and Terrible Science? • CRIMINALIZATION HAS NO EFFECT ON BEHAVIOR & UNDERMINES PUBLIC HEALTH GOALS • Studies show that the criminalization of HIV exposure has no effect on risk behavior. • HIV criminalization can discourage individuals from seeking testing and treatment because a positive test result subjects a person to criminal liability for otherwise non-criminal conduct. • Health care providers frequently are forced to disclose HIV-related medical records, including documentation of private communications, as part of a criminal investigation or trial, interfering with the physician-patient relationship and the delivery of health services and generating mistrust among patients. • Sex between two consenting adults is a shared decision; the responsibility for protection against disease should not be borne by one partner. Placing exclusive responsibility on the person living with HIV undermines public health messages that everyone should take responsibility for individual sexual health. • Criminalization further stigmatizes an already marginalized population, and reinforces ignorance and unfounded beliefs about the routes and actual risks of HIV transmission. Positive Justice Project, 2013

47. Early Government Intervention: Financial Support Public Health Initiatives Research Protection under the Law Knowledge Changing/Improving Social Determinants Activisms Prevention IS Care Prevention Tools Testing Medical Prevention Tools Multidisplinary Criminalization Stigma

48. From here … “BMS Internal”

49. HIV/AIDS and Public Health Karina Danvers Director, CT-LPS New England AIDS Education and Training Center Yale AIDS Program Yale School of Medicine