INTERSECTING EPIDEMICS IN THE NEW ENGLAND EPICENTER: HIV AND STD AT FENWAY COMMUNITY HEALTH

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HIV Prevention UpdateWhat Can Be Done to Slow
the Epidemic, and What Do We Need to Know?
Kenneth H. Mayer, MD Professor of Medicine and
Community Health Brown University-The Miriam
Hospital
The International AIDS SocietyUSA
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HIV Incidence in the United States
Pre-ARV
Pre-HAART
HAART Era

150
100
HIV Incidence (1,000s)

50
0
1985
1990
1995
2000
2005
2007
1980
Year
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What have we learned about the US Epidemic?

• Localized rather than generalized
• Evidence of recent infection clusters
• Many become infected despite lower rates of
  traditional risk behaviors
• Less likely to be aware of HIV status
• Less likely to benefit from advances in ART

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Attributable risk for HIV infection - EXPLORE
Koblin et al, AIDS 2006
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HIV TRANSMISSION

• Significant, but low probability event
  
• lt1/100 per contact transmission rate
• Multiple co-factors involved
• ? plasma viral load? ? transmission
• Can decreasing PVL with HAART ? transmission?
• Sexually transmitted infections (STI) ? HIV
  transmission and acquisition
  Can STI control ? HIV spread?
• Blood and genital tract HIV tend to change in
  parallel, but local factors alter HIV expression
  in different compartments
• Biological issues mediated by behaviors-inextricab
  ly interwoven
• 
  
  

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Plasma HIV RNA Predicts Likelihood of HIV
Transmission
30
Male-to-Female Transmission
Female-to-Male Transmission
All subjects
25
20
Transmission rate per 100 person-years
15
10
5
0
lt400
lt400
lt400
400-3499
400-3499
400-3499
gt50,000
gt50,000
gt50,000
3500-9999
3500-9999
3500-9999
10,000-49,999
10,000-49,999
10,000-49,999
Viral load (HIV-1 RNA copies/mL) and HIV
transmission
Quinn et al. N Engl J Med. 2000.
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How HAART Could Alter HIV Transmission
? PVL
? Survival ? PLHIV
?
?
?
? Genital Tract HIV
? N of Possible Encounters
?
?
? Transmission
? Transmission
Relevant issuesaccess, adherence, prevention,
std rx.
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HIV Transmission in the 21st Century

• Emerging trends among the HIV-infected
• Increases in racial disparity
• Increases in unsafe sex
• Increases in syphilis, gonorrhea
• Transmission of drug-resistant virus
• STDs increase amount of HIV shed at genital
  mucosa (cervix, urethra, rectum)
• Directly increases risk of transmitting HIV

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Why is this occurring?

• Improved HIV therapy, well-being, and survival
• Prevention fatigue
• Increased use of erectile dysfunction drugs,
  methamphetamine, poppers
• Old new ways to meet partners
• Baths, parks
• Internet
• Anonymous partners
• HIV sero-sorting

(Ciesielski 2003, Katz 2002)
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Provider Barriers to Screening for Behavioral
Risk Factors

• Inexperience or discomfort asking questions
• Discomfort responding to issues that arise
• Incorrect assumptions about sexual behavior and
  risk
• Patient perception of stigma from a medical care
  provider
• Limited time is available
• Perceived re-imbursement issues

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Overcoming Barriers

• Identify specific questions to ask all patients
• Train providers to enhance competence
• Develop clinic policy for risk screening and
  integration into overall care (When and Where)
• Questionnaire, CASI
• Develop plan to respond to information that might
  surface
• Determine ways to overcome stigma

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Typical components (models) of individual or
small group interventions

• Information / AIDS prevention education
  (not enough on its own)
• Motivation Enhancement
• Skills Training
• (J. D. Fisher Fisher, 1992)
• www.cdc.gov/hiv/topics/research/prs/prs_rep_debi.h
  tm
• Diffusion of Evidence-Based Interventions

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Revised CDC Recommendations for HIV Testing in
Healthcare Settings

• Routine voluntary testing for patients ages 13 to
  64 years in healthcare settings
• Not risk-based
• Opt-out testing
• No separate consent for HIV
• Pretest counseling not required
• Repeat HIV testing left to discretion of provider
• Based on patient risk

Branson BM, et al. MMWR. 2006
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Serostatus Awareness and HIV
Transmission
Accounting for
25 Unaware of Infection
54of New Infections
75Aware of Infection
46 of New Infections
People Livingwith HIV/AIDS(1,039,000-1,185,000)
New Sexual Infections Each Year(32,000)
Marks et al. AIDS. 2006201447.
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CONCLUSIONS

• Vaccines and microbicides are years away-
  behavioral interventions, STD control, and
  antiretrovirals are available now
• The reasons for ongoing HIV risk taking involve
  multiple situational and psychological factors
• No current intervention is expected to be 100
  protective, so further biobehavioral studies will
  be needed.
• Each component needs to become part of a
  combination strategy, analogous to HAART.