HIV Prevention by Ryan Biehle, Christine Griesmer, & Sadaf Samay

HIV Prevention 

What is HIV?

HIV (human immunodeficiency virus) is a virus that attacks the immune system and weakens its ability to fight infections and other illnesses. HIV is passed through blood, semen, vaginal fluid, pre-ejaculate, and breast milk, and can lead to AIDS (acquired immune deficiency syndrome) when a person’s CD4 (T-cell) count falls below 200. 

Statistics

An estimated 50,000 people are diagnosed with HIV every year, and in 2009 nearly 1.15 million people in the United States were living with the virus. According to 2010 data, 8,369 people died from HIV related causes.

The highest rates of HIV are found in southeast and northeast United States, such as Florida, Georgia, South Carolina, New York, and Washington D.C. The lowest rates are found in the northern states such as Montana, Wyoming, and the Dakotas. Colorado falls right in the middle, with prevalence rates of about 202.5-319.3 per 100,000 people. 

The graph below breaks down HIV incidence into subgroups. According to the graph, White homosexual men are at highest risk for HIV, followed by Black and Hispanic homosexual men. Black heterosexual women closely follow the trend, but it is clear that overall HIV affects more men than women.

The CDC has identified HIV in the U.S. as one of its Winnable Battles because it is preventable with sound policy and effective intervention programs focused on education, safe sex practices, and safe needle use.

In this brief video, the CDC highlights the importance of HIV prevention in public health: 

CDC Video on HIV

Brief History & Timeline of HIV

HIV was first noticed in the United States in 1981, when a handful of gay men in New York and California were diagnosed with rare cancers such as Kaposi's Sarcoma and/or Pneumocystis Pneumonia Carinii (PCP). Both conditions are extremely rare and only seen in highly immune compromised individuals. 

At first, the condition was thought to be related to gay behaviors and was named GRID (gay-related immune deficiency) accordingly. However, in mid-1982 similar illnesses were being reported in heterosexuals as well and that theory came into question. Further research led to a better understanding of the virus, and by 1984 we began to recognize HIV/AIDS as we understand it today.

The following brochure from 1988 was circulated all over the United States in an effort to prevent HIV/AIDS. 

CDC Targets & Healthy People Objectives

OVERARCHING GOAL = Prevent new HIV infections and ensure quality health care for persons living with HIV

TARGETS
The number of new HIV infections - BASELINE = 48,600 new HIV infections (2006), TARGET 2015 = 36,450 new HIV infections (25% reduction)

Key Actions

• Reduce HIV incidence in the United States
• Maximize the proportion of people with HIV who have suppressed viral load by improving diagnosis, linkage and retention in care, and antiretroviral provision and adherence
• Implement comprehensive prevention with positives and with high-risk negatives 
• Improve data monitoring, dissemination, and feedback
• Reduce HIV-related disparities

RELEVANT HEALTHY PEOPLE OBJECTIVES:

HIV 3   Reduce the rate of HIV transmission among adolescents and adults
                2020 Target: 3.5 new infections per 100 persons living with HIV
                Baseline: 4.58 new infections per 100 persons living with HIV (2006)
HIV 12  Reduce deaths from HIV infection
                2020 Target: 3.3 deaths per 100,000 population
                Baseline: 3.7 deaths per 100,000 population (2007)
HIV 13  Increase the proportion of people living with HIV who know their serostatus
                2020 Target: 90.0%
                Baseline: 80.6% (2006)

5 Interventions

1. Linkage to care/Retention

     Improving the health of persons with HIV and reducing the number of new HIV infections in the United States will depend on increasing access to HIV medical care and eliminating disparities in the quality of care received. To advance these goals, clinicians and community-based HIV prevention providers can support persons diagnosed with HIV infection to fully engage in HIV medical care.

      Currently, about 60% of persons with HIV have been tested and have had at least one HIV care visit. However, only about 50% of persons diagnosed with HIV receive regular HIV care. Of those retained in care, 89% are prescribed antiretroviral therapy and 77% achieve viral suppression.  Thus, only about 28% of all persons with HIV in the United States have suppressed viral loads. Without a substantial increase in the proportion of persons with HIV who have suppressed viral load, about 1.2 million new HIV infections can be expected to occur in the United States over the next 20 years.

      SOME RECOMMENDATIONS: Educate persons at the time of their HIV diagnosis about the benefits of HIV medical care for improving personal health and preventing HIV transmission.

Establish the infrastructure and services to assist persons with HIV to start HIV medical care shortly after a positive HIV test result, support long-term retention in HIV medical care, and re-engage into HIV medical care persons if they have dropped out of care.  Offer services that promote linkage to and retention in care through collaborations among HIV testing providers, community-based HIV prevention providers, HIV care providers, case managers, and health departments.

2. 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. When used consistently, PrEP has been shown to be effective in men who have sex with men (MSM) and heterosexually-active men and women. Based on studies to date, in July 2012 the U.S. Food and Drug Administration approved the combination medication tenofovir disoproxil fumarate plus emtricitabine (TDF/FTC, also known as TRUVADA) for use as PrEP among sexually active adults at risk for HIV infection.

       For some individuals at high risk for HIV infection, PrEP may represent a much-needed additional prevention method, but it will not be right for everyone and is not intended to be used in isolation, but rather in combination with other methods to reduce the risk of getting HIV infection. If it is delivered effectively and targeted to those at highest risk, PrEP may play a role in helping to reduce the significant continuing toll of new HIV infections in the United States. CDC is currently working with partners to ensure safe and effective PrEP use and begin to address key questions about acceptability, access, adherence, behavioral risks, and patient outcomes in community settings.

3. HIV Treatment as prevention benefit/ Test & Treat

        As a concept and a strategy, treating HIV-infected persons to improve their health and to reduce the risk of onward transmission—sometimes called treatment as prevention— refers to the personal and public health benefits of using ART to continuously suppress HIV viral load in the blood and genital fluids, which decreases the risk of transmitting the virus to others.

       The ability of antiretroviral drugs to prevent secondary transmission of HIV from an infected person to an uninfected sexual or drug-using partner has led to several proposed “test-and-treat” strategies. Test-and-treat programs are based on the premise that the rate of new HIV infections will be maximally reduced by using aggressive methods to test and diagnose all people living with HIV infection, treat them with ART regardless of CD4 cell count or viral load at diagnosis, and link them to care.

4. Behavioral Interventions & Education

       

     The Diffusion of Effective Behavioral Interventions project (DEBI) is a national-level strategy to provide high quality training and on-going technical assistance on selected evidence-based HIV/STD/ Viral Hepatitis prevention interventions to state and community HIV/STD program staff.  The interventions have been proven effective through research studies that showed positive behavioral (e.g., use of condoms; reduction in number of partners) and/or health outcomes (e.g., reduction in the number of new STD infections).

       The Behavioral Prevention Training Centers (Behavioral PTCs) provide courses that teach the use of evidence-based STD/HIV prevention interventions at the individual, group, and community level. Training is also provided in areas of program support needed to implement and maintain such interventions.  The intended target audience is prevention providers in public, private, and community sectors who are responsible for the implementation or supervision of STD/HIV prevention programs in community, clinic-based, or criminal justice settings. These courses teach skills and strategies to influence changes in behaviors that place people at risk for STD or HIV infection.

       Studies have shown that HIV risk behaviors can be reduced in any targeted population through interventions that provide risk reduction counseling, stress cognitive approaches to problem solving and behavior change, and help individuals to build the skills they need to reduce HIV risk. Voluntary counseling and testing (VCT) has also been clearly shown to reduce risk behaviors, especially among HIV-infected persons and in extramarital partnerships.

5. Research

       

     Historically, vaccines have been our best weapon against the world’s deadliest infectious diseases, including smallpox, polio, measles, and yellow fever. Unfortunately, we do not have a vaccine for HIV. HIV has unique ways of evading the immune system and the human body seems incapable of mounting an effective immune response against virus. As a result, scientists do not have a clear picture of what is needed to provide protection against the virus.  Finding a safe, effective and durable HIV vaccine remains a top priority for the HIV community (NIH/NIAID) and that will only happen with continued research.

      Basic scientific information about how the virus attacks the body and how the body defends itself is critical to feeding the pipeline that generates new targets against which therapeutic interventions and vaccines can be directed.

Recommendations to win the battle against HIV/AIDS

HIV is a preventable disease and the CDC has labeled HIV as one of the 10 winnable health battles. So what can we do to win the fight?

What can I do?

·         Get tested and know your status! 1 in 5 Americans who have HIV do not know that they are infected. Getting tested can lead to effective treatment and prevent the spread of HIV (CDC 2013).

·         See your doctor and get treatment. There are now effective treatments to help people with HIV live longer, healthier and more productive lives. Getting the proper medical care and treatment can lead to a healthier life and help prevent the spread of HIV (Healthy People 2013).

·         Lobby your representative. President Obama’s 2013 budget proposal included a 3% increase in HIV/AIDS funding. Call your U.S. Congressman or Senator to tell them to support similar funding in next year’s budget, and to ensure the budge sequestration does not affect HIV/AIDS funding (Kaiser Family Foundation 2012).

What can doctors and health care professionals do?

·         Counseling and education. Doctors and other health professionals can provide HIV prevention counseling, as well as counseling on relevant treatments when appropriate. Community-based outreach and education to at-risk populations can help decrease HIV prevalence.

·         Offer testing. Doctors can offer regular STD testing, including for HIV. Only 45% of people with HIV received prevention counseling from their doctors in the past year (CDC Vital Signs 2011). If cost is a concern, doctors can refer patients to appropriate free or low-cost resources.

What can governments and health departments do?

·         Target interventions. HIV disproportionately affects men, particularly gay and bisexual men, and African Americans. Governments and local health departments can significantly curb the spread of HIV by appropriately targeting resources. By funding programs that do outreach and use effective treatments in high-risk communities, the return on investments will be significantly greater for the overall public health.

·         Conduct public health surveillance. Effective surveillance of HIV cases in every community can help identify higher-risk regions, unusual trends and possible outbreaks. This surveillance can help officials better target resources to prevent the spread of HIV.

·         Fund HIV research. Federal and state governments can provide grant funding through the National Institutes of Health or other entities to support promising research on effective HIV interventions.

Additional Resources

• Know your status! Click to find an HIV testing site near you
• Act Against AIDS
• Click for a Video on HIV/AIDS facts
• Click for a map of HIV prevalence around the United States
• Click for a comprehensive set of federal funding resources and HIV/AIDS frequently asked questions
• Click for a CDC presentation on HIV/AIDS statistics.

Sources

Avert (2013). AIDS Timeline. Retrieved May 10, 2013 from http://www.avert.org/aids-timeline.htm

Centers for Disease Control and Prevention. Act Against Aids. Retrieved May 11, 2013 from http://www.cdc.gov/actagainstaids/index.html

Centers for Disease Control and Prevention. 10 Winnable Battles: HIV. Retrieved May 11, 2013 from http://www.cdc.gov/vitalsigns/HIVtesting/index.html

Centers for Disease Control and Prevention. HIV/AIDS: Basic Statistics. Retrieved May 12, 2013 from http://www.cdc.gov/hiv/basics/statistics.html

Centers for Disease Control and Prevention. Vital Signs: New Hope for Stopping HIV. December 2011. Retrieved May 11, 2013 from http://www.cdc.gov/vitalsigns/HIVtesting/index.html

Centers for Disease Controld and Prevention. Winnable Battles: HIV Prevention. Retrieved May 12, 2013 from http://www.cdc.gov/winnablebattles/101/HIV/index.html

Effective Interventions: HIV Preventions that Work. Behavioral Interventions. Retrieved May 12, 2013 from http://www.effectiveinterventions.org/en/HighImpactPrevention/Interventions.aspx

Healthy People 2020. HIV Overview. Retrieved May 11, 2013 from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=22

Kaiser Family Foundation (2012). HIV/AIDS Policy Fact Sheet: U.S. Federal Funding for HIV/AIDS: The President’s FY 2013 Budget Request. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7029-08.pdf

National Institutes of Health (2013). HIV/AIDS. Retrieved May 12, 2013 from http://www.niaid.nih.gov/topics/hivaids/Pages/Default.aspx