2. Burden of HIV in the United States
1.1 million people living with HIV
Net increase of 40,000 people with HIV infections each
year
56,000 new infections (2006)
16,000 deaths (2006)
HIV infected people who start antiretroviral treatment
(ART) are now expected to live at least an additional 35
years
Lifetime treatment costs of ~$400,000
3. Number of people living with HIV continues to
increase sharply
HIV Incidence and Prevalence, United States, 1977–2006
1,200,000
New HIV Infections (Incidence)
1,000,000
People Living With HIV/AIDS (Prevalence)
800,000
600,000
400,000
200,000
0
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
JAMA 2008;300(5):520-529.Campsmith M, et al. CROI 2009.
4. Stark disparities in HIV/AIDS among different
groups
95% of people with AIDS are MSM, African
American, Latino, or IDU
African Americans are 8 times more likely than whites
to have HIV
Latinos are 3 times more likely to have HIV than whites
MSM are >40 times more likely to have HIV than other
men and women
CDC, HIV Surveillance Report,2008. Published June 2010. www.cdc.gov/hiv/surveillance/resources/reports
MSM = Men having sex with men
IDU = Intravenous drug users
5. From 2005-2008, the percentage of HIV diagnoses
attributed to male-to-male sexual contact
increased — 37 states and 5 U.S. dependent areas
Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis.
Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005.
All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and
missing risk-factor information, but not for incomplete reporting.
1Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
2 Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
6. In 2008, the majority of HIV diagnoses among males were attributed to
male-to-male sexual contact; among females the majority were
attributed to heterosexual contact — 37 states and 5 U.S. dependent
areas
Males
N=31,595
4%
15%
72%
Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis.
Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005.
All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and
missing risk-factor information, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
7. From 2005-2008, the percentage of HIV diagnoses
increased among Blacks/African Americans – 37 states
and 5 U.S. dependent areas
,%
Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis.
Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005.
All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not
for incomplete reporting.
a Hispanics/Latinos can be of any race.
8. HIV prevention works
Saves lives and money
Our collective prevention efforts have led to a
dramatic reduction in HIV infections
• Estimated number of new HIV infections per year was 130,000 in
1985
• Down to an estimated 56,000 new HIV infections per year in 2006
Conservative estimates are that prevention
efforts have:
• Averted more than 350,000 HIV infections in the United States
• Saved more than $125 billion in medical costs
Source: Holtgrave DR. Written testimony on HIV/AIDS incidence and prevention for the US House of Representatives Committee on
Oversight and Government Reform. September 16, 2008.
9. Key HIV prevention strategies
Promote:
Abstinence (or delaying sex)
Fewer sexual partners (ideally, monogamous
relationship with an uninfected partner)
Consistent and correct use of condoms
(male/female)
Not sharing syringes for injection drug use
10. Cost benefits of HIV prevention
Pennies ~$400,000
Cost of condoms Lifetime cost of
treating one HIV-
infected person
11. Other HIV prevention strategies
Antiretroviral drugs (ARVs):
• To prevent perinatal
transmission
• To reduce infectiousness
• To prevent new infections (as
Pre-Exposure Prophylaxis
[PrEP])
Male circumcision
• To reduce risk of HIV infection
through penile-vaginal sex
12. Pre-Exposure Prophylaxis (PrEP)
Potential users: HIV-uninfected persons at high
risk of becoming infected
• High risk may include sexual partner who has HIV, multiple
partners, frequent STDs, or other evidence of high risk
• Recent trial demonstrates the safety and efficacy of PrEP for MSM
at high risk
Cost-effectiveness depends on:
• HIV incidence in target groups
• Cost of medication and services
• Ability to maintain or increase existing risk reduction behavior
• Adherence to medication
• $34,000-$320,000 per QALY saved
Source: Paltiel et al. CID 2009:48(6):806-816 Smith, et al. MMWR 2011:60(03);65-68
13. PrEP with daily tenofovir/emtracitabine can
reduce HIV risk in MSM
44% reduction in acquisition
Source: Grant RM et al. (2010). NEJM; published online Nov. 23, 2010.
14. Policy, Systems, and Environmental Change
Integrating Prevention and Healthcare
Policy development and support
Guidelines and recommendations (testing, prevention
with positives, ART)
Quality measures: Development and uptake
Reimbursement coding guidance
15. Policy, Systems, and Environmental Change
Integrating Prevention and Healthcare
New programs and models
Expanded Testing Initiative: 30 jurisdictions covering
>90% of epidemic
• Over 2.6 million HIV tests conducted; 27,000 HIV infections
diagnosed
Enhanced HIV Prevention Planning: 12 urban areas
covering 44% of epidemic
• Integrating HIV prevention, care, treatment services across health
care system and community
16. Testing and diagnosis is prevention
21% (230,000) with
undiagnosed HIV
• Account for approximately
50% of new HIV
transmissions
79% (870,000) with
diagnosed HIV
• More likely than
undiagnosed to access
prevention and treatment
Source: Marks G, et al (2006). AIDS 20(10): 1447-1450.
17. HIV testing is a prevention strategy
CDC’s 2006 HIV Testing Recommendations for Health
Care Settings
• Promote routine screening of patients age 13-64
Routine, opt-out screening in clinical settings
costs $2,000-$6,000 per HIV diagnosis
confirmed
Source: Campsmith M et al. (2010). JAIDS 53:619--24.
18. Key approaches and program considerations in
HIV prevention
HIV testing and linkage to care
Prevention with positives
Policy and structural interventions
Targeted interventions
Surveillance, monitoring, and evaluation
Evidence-based planning
Health equity
Health reform
Program collaboration and service integration
19. Focusing resources
Burden of disease
• Geographic distribution
• Groups disproportionately affected by HIV (MSM, African
Americans, Latinos, injection drug users)
HIV prevention services
• For people living with HIV
• For people at high risk for HIV infection
Monitoring the epidemic, sharing, and using
information
Discovering and operationalizing new interventions
20. Maximizing impact
Target programs to people and geographic areas most
at risk for transmission or acquisition
Focus on interventions with evidence for large effect
size
Choose feasible efforts with potential for large-scale
implementation
21. ―The United States will become a place where new HIV
infections are rare and when they do occur, every
person, regardless of age, gender, race/ethnicity, sexual
orientation, gender identity or socio-economic
circumstance, will have unfettered access to high
quality, life-extending care, free from stigma and
discrimination.‖
—Vision of the National HIV/AIDS Strategy
Editor's Notes
Chart description: HIV incidence and prevalence in the United States, 1977-2006. The number of people living with HIV/AIDS (prevalence) in 1977 was 600. In 1978, it was 1,200. In 1979, it was 1,800. In 1980, it was 22,000. In 1981, it was 42,000. In 1982, it was 106,000. In 1983, it was 170,000. In 1984, 297,000. In 1985, it was 420,000. In 1986, it was 493,000. In 1987, it was 562,000. In 1988, it was 625,000. In 1989, it was 683,000. In 1990, it was 735,000. In 1991, it was 748,000. In 1992, it was 754,000. In 1993, it was 757,000. In 1994, it was 754,000. In 1995, it was 750,000. In 1996, it was 759,000. In 1997, it was 792,000. In 1998, it was 827,000. In 1999, it was 863,000. In 2000, it was 897,000. In 2001, it was 929,000. In 2002, it was 961,000. In 2003, it was 994,000. In 2004, it was 1,031,000. In 2005, it was 1,067,000. In 2006, it was 1,107,000. The number of new HIV infections (incidence) in 1977 was 600. In 1978, it was 600. In 1979, it was 600. In 1980, it was 20,000. In 1981, it was 20,000. In 1982, it was 64,900. In 1983, it was 64,900. In 1984, 130,400. In 1985, it was 130,400. In 1986, it was 84,800. In 1987, it was 84,800. In 1988, it was 84,800. In 1989, it was 84,200. In 1990, it was 84,200. In 1991, it was 48,700. In 1992, it was 48,700. In 1993, it was 48,700. In 1994, it was 48,800. In 1995, it was 48,800. In 1996, it was 48,800. In 1997, it was 58,400. In 1998, it was 58,400. In 1999, it was 58,400. In 2000, it was 55,300. In 2001, it was 55,300. In 2002, it was 55,300. In 2003, it was 55,400. In 2004, it was 55,400. In 2005, it was 55,400. In 2006, it was 55,400.
Diagnoses of HIV Infection among Adults and Adolescents, by Transmission Category, 2005–2008—37 States and 5 U.S. Dependent AreasThis slide presents the distribution of diagnoses of HIV infection among adults and adolescents diagnosed from 2005 through 2008, by transmission category, for 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. The percentage of diagnoses of HIV infection among adults and adolescents exposed through male-to-male sexual contact increased from 50% in 2005 to 54% in 2008. The percentage of diagnoses of HIV infection among adults and adolescents exposed through heterosexual contact remained stable during this time. The percentage of diagnoses among adults and adolescents exposed through injection drug use and through male-to-male sexual contact and injection drug use decreased from 2005 through 2008. The remaining diagnoses of HIV infection were those attributed to hemophilia or the receipt of blood or blood products, and those in persons without an identified risk factor. The following 37 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2005: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. The 5 U.S. dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands.Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. Heterosexual contact is with a person known to have or to be at high risk for HIV infection. Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Chart description:Diagnoses of HIV Infection among Adults and Adolescents, by Sex and Transmission Category, 2008—37 States and 5 U.S. Dependent AreasIn 2008, among male adults and adolescents diagnosed with HIV infection in the 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005, 72% were attributed to male-to-male sexual contact and 9% were attributed to injection drug use. Approximately 15% of cases were attributed to heterosexual contact and 4% attributed to male-to-male sexual contact and injection drug use. Most (84%) of the diagnoses of HIV infection among female adults and adolescents were attributed to heterosexual contact, and 15% were attributed to injection drug use. The following 37 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2005: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. The 5 U.S. dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands.Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. Heterosexual contact is with a person known to have or to be at high risk for HIV infection.Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Chart description: Diagnoses of HIV Infection among Adults and Adolescents, by Race/Ethnicity, 2005–2008—37 States and 5 U.S. Dependent Areas From 2005-2008, blacks/African Americans constituted the largest percentage of diagnoses of HIV infection each year. In 2008, of adults and adolescents diagnosed with HIV infection in 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005, 50% were black/African American, 28% were white, 20% were Hispanic/Latino, 1% were Asian, 1% were of multiple races, and less than 1% each were American Indian/Alaska Native and Native Hawaiian/other Pacific Islander. The following 37 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2005: Alabama, Alaska, Arizona, Arkansas, Colorado, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. The 5 U.S. dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands.Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Hispanics/Latinos can be of any race. Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005. All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. a Hispanics/Latinos can be of any race.
The chart shows a 44% reduction in acquisition for men who have sex with men (MSM) with the use of Pre-Exposure Prophylaxis with daily tenofovir/emtracitabine use