Chris Beyrer: "State of the Science: Key populations"
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3. State of the Science:
Key Populations
Chris Beyrer MD, MPH
President, The International AIDS Society
4. Key Populations in HIV
Key populations: those individuals and communities who have
disproportionate burdens of HIV risk and disease and lack of
access to essential HIV services
• Gay, Bisexual, and other men who have sex with men
(MSM)
• Sex Workers of all genders
• People who inject drugs (PWID)
• Transgender Women who have sex with men
• Women and Girls in South, East African hyper-epidemics
• Adolescents from all of these communities
5. Global Prevalence of HIV in PWID
Worldwide were an estimated 12.7 million PWID in 2014: 1.7 million
living with HIV (some 13% all HIV cases)
6. In Greece there were: 2000-2010, 9-19 new HIV
cases in IDU (2%–3% of all cases); in 2011, 266
cases in IDU ( 28% of HIV cases) and in 2012, 547
cases in IDU (46% of HIV cases)
HIV can Disseminate very rapidly among PWID
Outbreak of HIV Linked to
Oxymorphone in Indiana,
USA, 2015
80%
3%
17%
Injection Drug Use
No Injection Drug Use
Not Interviewed to
Determine Status
Average 9 syringe-sharing
partners, sex partners
Outbreak of HIV in
Greece and Romania
In Scott County, which is a community of
4200 people there have been 173 new HIV
Infections since January of 2015
7. Global HIV prevalence among adult women
sex workers, 2013.
Beyrer, et al, The Lancet, 2014.
8. Global HIV prevalence among adult women
sex workers, 2013.
Beyrer, et al, The Lancet, 2014.
9. HIV prevalence among transgender women,
2000-2011 Baral, Poteat, Beyrer LID, 2013
Pooled OR for HIV infection among TGW compared to
other reproductive people: 48.8 (95% CI 31.2-76.3)
11. Diagnoses of HIV Infection among Adult and Adolescent Males, by
Transmission Category, 2010-2014
United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statisticallyadjusted to account for reportingdelays and missing transmission category, 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, perinatalexposure, and risk factor not reported or identified.
12. Diagnoses of HIV Infection among Adults and Adolescents,
by Race/Ethnicity, 2010–2014—United States and
6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
13. Continuum of Care, Young MSM
353
181
145 140
100
59
0
50
100
150
200
250
300
350
0
20
40
60
80
100
HIV Infected HIV Diagnosed Linked to HIV
Care
Retained in
HIV Care
On ART Suppressed VL
Percentage
Engagement in HIV Care
Estimated number and percentage of HIV infected men who have sex with
men age 13-24 engaged in selected stages of the continuum of care,
Baltimore City, 2013
Using data as reported through 12/31/2014
15. Variable
Fear of Seeking Health Care OR
(95% CI)
Denied Health Care Services
OR (95% CI)
Blackmailed
OR (95% CI)
Diagnosed with an STI 2.4 (1.4-4.3) * 6.9 (3.0-15.6) ** 1.5 (0.8-2.7)
Treated for an STI 2.8 (1.7-4.9) ** 7.3 (3.3-16.2) ** 1.5 (0.8-2.6)
Received recommendation for
an HIV test
1.9 (1.2-3.0) * 2.2 (0.98-4.8) 1.8 (1.1-2.8) *
Ever tested for HIV 1.1 (0.7-1.7) 1.6 (0.7-3.7) 1.0 (0.7-1.6)
Self-Reported Diagnosis of HIV
or AIDS
2.6 (1.1-6.5) * 3.3 (0.9-12.1) 2.7 (1.1-6.6) *
Self-Reported Treatment for
HIV
3.7 (1.6-8.6) * 46.1 (17.3-122.8) ** 5.4 (2.2-13.2) **
HIV positive 1.7 (0.9-3.2) 1.2 (0.4-3.6) 0.9 (0.5-1.6)
Any interaction with health
care
2.6 (1.6-3.9) ** 6.4 (2.5-16.1) ** 2.1 (1.4-3.2) *
Pooled Data from Three Countries
* - p <0.05
** - p <0.01
Source: Fay H, Baral S, Trapence G, Motimedi F, Umar E, et al. Stigma, Health Care Access, and HIV Knowledge Among Men Who Have Sex With Men in Malawi, Namibia, and Botswana. AIDS and Behavior, Dec
2010: 1-10.
Associations between fear and experienced discrimination with sexual health
and use of services among MSM in Malawi, Botswana, and Namibia.
16. Effects of the Criminalization of Same-
Sex Practices in Nigeria
• Same-sex marriage bill introduced in Nigeria in January, 2014
further criminalizing same-sex relationships and associations with
community groups
• Methods
– MSM recruited through respondent-driven sampling and enrolled into
a prospective cohort in Abuja from March 2013-June 2014
– Characteristics related to discrimination and HIV care are described
and compared pre-post legislation using chi-squared statistics
– TRUST Model
• UMD/IHV HIV Prevention and Treatment Services co-located with community
group serving MSM (ICARH)
Sources: Schwartz, Nowak, Orazulike, Blattner, Charurat, Baral, TRUST Study Group (UMD, MHRP, ICARH, JHU). The immediate HIV-related impact of
enacted legislation that further criminalizes same-sex practices in Nigeria. Forthcoming
17. Outcomes of Criminalization on HIV-
Risks among MSM in Nigeria
Reporting of Discrimination and Stigma
During Study Visits Pre and Post Legislation
Cumulative lifetime experiences of reported
fear of seeking health care services across
study visits (n=1,175 visits).
Sources: Schwartz, Nowak, Orazulike, Blattner, Charurat, Baral, TRUST Study Group (UMD, MHRP, ICARH, JHU). The immediate HIV-related impact of
enacted legislation that further criminalizes same-sex practices in Nigeria. Forthcoming
18. Source: Bureau of Justice Statistics, 2009
ADULTS (+7M)
> 5.5M need SUD TX
JUVENILES (650K)
253,034 need SUD TX
14% of all people in
the US with HIV pass
through a correctional
facility per year
Incarceration Predicts Virologic
Failure for
HIV + PWID Receiving ART
Westergaard RP et al., HIV/AIDS 2011; 53: 725-731.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
No incarceration Incarceration during
prior 6 months
Had clinic visit
got ART
Clinic visit,
did not get ART
Got ART,
no clinic visit
Did not get ART,
no clinic visit
19. The Global Fund in Transition
• Since 2002 the Global Fund to Fight AIDS, Tuberculosis and Malaria has
mobilized more than 40 billion USD
• A funding crisis after its 10th round forced the GF board into announcing a new
approach
• The New Funding Model rolled out in 2014 uses an eligibility formula based on
national income and disease burden prioritizing lower-middle income countries
• Middle-income countries (MICs) receive much lower levels of GF support
• The burden HIV/TB is actually concentrated in MICs, with approximately 57% of
AIDS, 72% of TB, and 54% of malaria in MICs
• Three of the top five countries with the highest HIV burdens are middle income
and eight of the ten countries with the highest TB burdens are middle income
• Key Populations most affected—outside Africa, predominance of HIV is in KP
20. Source:A. Klepikov, International HIV/AIDS Alliance in Ukraine presentation, Barcelona meeting available at
https://www.opensocietyfoundations.org/sites/default/files/global-fund-crossroads-20150611.pdf
21. Predicted impact of GF transition on GF and Government funding in Ukraine
Source:A. Klepikov, International HIV/AIDS Alliance in Ukraine presentation, Barcelona meeting available at
https://www.opensocietyfoundations.org/sites/default/files/global-fund-crossroads-20150611.pdf
22. Insurer Says Clients on Daily Pill
Have Stayed H.I.V.-Free
The New York times
DONALD G. McNEIL Jr. SEPT. 2, 2015
23. No New HIV Infections with Increasing Use of HIV
Preexposure Prophylaxis in a Clinical Practice Setting
Jonathan E. Volk, J Marcus, T Phengrasamy, D Blechinger, DP Nguyen, Follansbee, and C.
Hare. Clinical Infectious Diseases, Sept. 2, 2015.
Abstract
Referrals for and initiation of pre-exposure prophylaxis (PrEP) for HIV
infection increased dramatically in a large clinical practice setting
since 2012. Despite high rates of sexually transmitted infections
among PrEP users and reported decreases in condom use in a subset,
there were no new HIV infections in this population.
657 people, followed over 36 months, 388/person years of
observation
99% MSM
25. Research Agenda
• Reducing incidence: PrEP implementation for Key
Populations
• Optimizing Treatment: MSM, PWID, SW, TG need
HIV testing, ARVs, PrEP platforms in safety and
dignity
• Tailored interventions across the continuum
needed to address LGBT health disparities
globally
• Next generation interventions and delivery
systems need to be designed for KP to achieve
control of HIV
26. Acknowledgements
Johns Hopkins
Stefan Baral, Tonia Poteat, Sheree
Schwartz, Brian Weir, Andrea Wirtz,
Anne Efron, Liz Bonomo, Richard
Chaisson, Nick
Sex Workers and HIV
Linda-Gail Bekker, Jenny Butler, Anna-
Louise Crago, Pam Das, Leigh
Johnson, Kate Shannon, Steffanie
Strathdee, Frances Cowan, Cheryl
Overs, Donela Besada, Sharon Hillier,
Ward Cates
Meg Doherty, Bob Grant, Gottfried
Hirnshchall, Michel Kazatchkine, Ken
Mayer, Owen Ryan, Michel Sidibe,
Nora Volkov
MSM Prevention: Patrick
Sullivan, Alex Carballo-Dieguez,
Thomas Coates, Steven M
Goodreau, Sybil Hosek, Ian
McGowan, Eduard J Sanders,
Adrian Smith, P. Goswami, Jorge
Sanchez
MSM Epidemiology
Frits van Griensven, Steven
Goodreau, Suwat Chariyalertsak,
Ron Brookmeyer, Pat Chaulk
Supported by grants to the Center for Public Health and Human Rights at John Hopkins from
amfAR the Foundation for AIDS Research
The Bill & Melinda Gates Foundation
Project Search, USAID
The John Hopkins Center for AIDS Research (NIAID, 1P30AI094189-01A1)
