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HIV/AIDS Prevention: Lessons from San Francisco

HIV/AIDS Prevention: Lessons from San Francisco. Mitchell D. Feldman, MD, MPhil Professor of Medicine Director of Faculty Mentoring University of California, San Francisco San Francisco, California USA. Epidemiology of HIV/AIDS in the United States. A brief overview.

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HIV/AIDS Prevention: Lessons from San Francisco

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  1. HIV/AIDS Prevention:Lessons from San Francisco Mitchell D. Feldman, MD, MPhil Professor of Medicine Director of Faculty Mentoring University of California, San Francisco San Francisco, California USA

  2. Epidemiology of HIV/AIDS in the United States • A brief overview . . .

  3. The U.S. Epidemic in 2007: Snapshot of Key Data

  4. New AIDS Cases, Deaths, and People Living with AIDS, 1985-2004 People Living with AIDS New AIDS Cases People Living with AIDS Deaths and New AIDS Diagnoses Deaths among People with AIDS 2004 Note: Data are estimates. Source: CDC, Data Request, 2006.

  5. AIDS Diagnoses by Race/Ethnicity, 2004 AIDS Cases U.S. Population 42,514 293,655,404 White, non-Hispanic 28% 69% African American 49% 13% Latino 14% 4% 20% Asian/Pacific Islander 1% 1% <1% AI/AN

  6. Women as a Share of New AIDS Diagnoses Note: Data are estimates. Sources: CDC, Data Request, 2006.

  7. Trends in HIV Transmission 1984-2004

  8. Delay in HIV Testing in U.S. • CDC surveyed 19,000 AIDS patients in 12 states between 1990 and 1999; 40% learned of their HIV status in the 12 months prior to being diagnosed with AIDS • Researchers with Kaiser Permanente examined the medical records of 434 HIV-positive patients and found that 40% "displayed symptoms of infection or told health care providers of risky behavior" more than a year before being diagnosed with HIV.

  9. Why the Delay in Testing? • People are avoiding HIV testing because they are "afraid of the results" • Among risk groups: • 39% of gay men delayed testing, • 40% of intravenous drug users tested late • 51% of people who became infected through heterosexual contact delayed testing. • “We don't like admitting to ourselves that we're at risk," (Leo Hurley, a Kaiser Permanente researcher)

  10. HIV/AIDS in San Francisco:An Overview

  11. California and SF AIDS Cases(4/07) • Cumulative Cases: 145,180 (pediatric=683) • Cumulative Deaths: 83,526 (pediatric=402) • San Francisco City/County • 27,108 cases • 18,287 deaths

  12. Characteristics of cumulative AIDS cases inSan Francisco, California, and USA

  13. Distribution of persons living with HIV/AIDS, San Francisco, December 2004

  14. Living HIV and AIDS cases by gender, San Francisco, December 2004

  15. Living male HIV and AIDS cases by race/ethnicity, San Francisco, December 2004

  16. Living female HIV and AIDS cases by race/ethnicity, San Francisco, December 2004

  17. Living male HIV and AIDS cases by exposure category, San Francisco, December 2004

  18. Living female HIV and AIDS cases by exposure category, San Francisco, December 2004

  19. HIV/AIDS Prevention in San Francisco:A story and lessons learned

  20. Background • In 1992, AIDS was the most common cause of death among men of all ages in SF • AIDS accounted for 15% deaths and 39% potential years lost before age 75 • By 1995, ~20,000 of estimated 58,000 MSM in SF diagnosed with AIDS • How did this happen?

  21. Gonococcal proctitisSF City Clinic1974-1986 Cases Year

  22. Annual Incidence HIV infection among Hepatitis-B vaccine trial participants1978-1988 (Retrospective Cohort Study) % infected with HIV Year

  23. AIDS cases, deaths, and prevalenceSan Francisco, 1980-2004

  24. Lesson 1 • Prevention works, but prevention efforts must focus on tracking the “leading edge” of the epidemic. • Prevention programs must be based on HIV incidence and not prevalence.

  25. Tracking the leading edge of the epidemic追蹤最新疫情 Mathematical model using back calculation from AIDS cases 用艾滋病病例倒推計算的數學模型 • Incidence peak 1982HIV發病在1982年到達高峰 • Missed it! Ten years too late也錯過了！晚了十年

  26. Why HIV incidence surveillance? 為什麼要做HIV-1發病監測？ “If you can describe the most recent 100 persons infected with HIV, you have the key to the epidemic”-- Kevin De Cock Kevin De Cock說：如果你可以描述最近一百個HIV感染者的狀況，你就掌握這個流行病的疫情了。

  27. HIV incidence vs. HIV prevalence HIV發病和患病的監測 Surveillance: 監測 The systematic and on-going tracking of the occurrence of disease for use in public health在公共衛生領域中所使用對疾病發生有系統和持續的追蹤 HIV incidence: HIV發病率 The rate of new HIV infection in a population over a period of time 在特定的一段期間內，在一人口族群中新感染HIV的比率 HIV prevalence: HIV患病率 The proportion of persons living with HIV/AIDS in a population at a single point in time在特定的一個時間點，在一人口族群中HIV/AIDS存活者所佔的比例

  28. HIV prevalence vs. HIV incidenceHIV患病率和發病率 Source: Sentinel surveillance at the city’s STI clinic 來源：性病診所的哨點監測 HIV prevalence (gay men) HIV患病率(男同性戀) Trends in HIV prevalence do not always mirror trends in HIV incidence 患病率不見得總是反映發病率的 HIV incidence (gay men) HIV發病率(男同性戀)

  29. HIV prevalence vs. HIV incidenceHIV患病率和發病率 HIV prevalence: HIV患病情況可用於 • Where the epidemic has been了解疫情已在何處 • Relative burden of disease 了解疾病相對負擔 • Projecting future health care needs規畫未來健康照護的需要 HIV incidence: HIV發病情況可用於 • Where the epidemic is now了解疫情現在何處

  30. HIV incidence, San Francisco Rise Fall Reversal of trend ? Resurgence Nadir

  31. Lesson 2 • HIV prevention must always adapt to changing conditions.

  32. HIV prevalence among MSM by age, the National Behavioral Surveillance Survey, San Francisco, 2003-2004

  33. Percent of MSM reporting unprotected anal intercourse by self-reported HIV status in the last six months, 1998-2004

  34. Male rectal gonorrhea and male gonococcal proctitis among MSM, San Francisco, 1997-2004

  35. Syphilis among MSM, San Francisco, 1997-2004

  36. Lesson 3 • HIV prevention messages must be targeted to the risk group. • Example: Asian MSM in SF

  37. Male AIDS Cases per 100,000 in 2004, San Francisco2004年舊金山男性每十萬人中的艾滋病例數 Surpassed whites in 1996 在1996年超過白人 Surpassed whites in 2003 在2003年超過白人 拉丁裔 亞裔 非裔 白人

  38. HIV incidence among gay men, 2001追蹤最新疫情：2001年男同性戀的HIV發病率 Pending disaster or prevention opportunity? 即將發生的災難或預防的機會？ HIV incidence testing at VCT 自願性諮詢和檢測中心的HIV發病檢測 拉丁裔 非裔 白人 亞裔

  39. Unprotected anal sex among Asian vs. white gay men, San Francisco舊金山亞裔和白人男同性戀無保護肛交 White白人 Asian亞裔

  40. Rectal gonorrhea among Asian vs. white gay men, San Francisco舊金山亞裔和白人男同性戀的直腸淋病 Asian亞裔 White白人

  41. Targeting Prevention Programs設定預防項目的目標 • Heighten awareness of HIV risk among Asian gay men 提高亞裔男同性戀對HIV的危險意識 • Increase HIV testing among Asian gay men 增加亞裔男同性戀的HIV檢測 • Enhanced STI screening and treatment for Asian gay men 強化亞裔男同性戀的性病篩檢和治療 • CDC-funded study specifically for Asian gay men 中央資助針對亞裔男同性戀的研究項目 • Increase resource allocation to Asian gay men增加提供亞裔男同性戀的資源分配

  42. Lesson 4 • Prevention must also focus on those already HIV+.

  43. Developing new HIV prevention programs開發新的預防項目 • Prevention for Positives 對HIV陽性者的預防的措施 • Intensified efforts in 1999-2001 於1999至2001年間加強預防的努力 • Physician training in prevention for persons on ART 教導醫生如何針對使用抗病毒藥物的病患做預防工作 • HIV+ support groups HIV陽性的支援團體 • Counseling on disclosing HIV sero-status to partners 輔導告知伴侶HIV血清狀態 • Media campaigns 媒體宣傳

  44. Lesson 5: • HIV testing and treatment can save lives.

  45. Monitoring and evaluation of prevention programs: 2004 NHBS for gay men監視和評估預防項目：2004年男同性戀的行為監測 Among 5 cities, San Francisco had the highest level of HIV testing舊金山在五個城市中有最高的檢測率 巴爾地摩 紐約 舊金山 洛杉磯 Note: Not available for Miami沒有邁阿密的數據

  46. Monitoring and evaluation of prevention programs: 2004 NHBS for gay men監視和評估預防項目：2004年男同性戀的行為監測 Among 5 cities, San Francisco had the lowest level of unknown HIV infection舊金山在五個城市中有最低的HIV感染未知 巴爾地摩 紐約 邁阿密 舊金山 洛杉磯

  47. Use of HIV antiretrovirals and HAART among persons living with AIDS by year, San Francisco, 1995-2004

  48. Use of HAART among persons living with AIDS by gender, race/ethnicity, and exposure category, San Francisco, December 2004

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