3. Disclosures
Original slide developer: Michelle Iandiorio, MD
Clinical Director, SCAETC; Professor, UNMHSC Dept of Internal
Med, Division of Infectious Diseases
Slide developer has no financial conflicts of interest to disclose
Slide presenter has spoken for Merck in the past
3
This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human
Services (HHS) as part of an award totaling $3,132,205, with 0% financed with non-governmental sources.
The views expressed do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention
of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. Any trade/brand names for
products mentioned during this presentation are for training and identification purposes only.
This project is supported by funds from the Bureau of Primary Care.
4. Learning Objectives
1. Recognize the need for HIV screening and prevention.
2. Recognize disparities in accessing HIV prevention.
3. Identify HIV screening guidelines and explain why HIV
screening is routine best practice.
4. Explain status neutral linkage to care.
4
5. There have been improvements in reduction of new
HIV diagnoses…
Annual number of new diagnoses decreased 8%
from 2015 to 2019 in U.S. (36,000)
Majority of new diagnoses in men with male sex
partners
From 2010 to 2019, HIV diagnoses decreased
among youth overall
2019 HIV infections decreased among 13-
24yo by 46%
https://www.cdc.gov/hiv/statistics/overview/ataglance.html
6. … But Disparities Still Exist
New HIV diagnoses in Native American population
increased 22% between 2015 to 2019 (31% in
Native American men with male sex partners)
From 2010 to 2016, HIV diagnoses increased 6%
among Latinx
The most affected subpopulation is African
American/Black gay and bisexual men
https://www.cdc.gov/hiv/statistics/overview/ataglance.html
MSM=men who have sex with men
https://www.cdc.gov/hiv/statistics/overview/ataglance.html
7. Not all People with
HIV know their status
1,059,784 PWH 2019
http://www.cdc.gov/hiv/statistics/overview/ataglance.html
8. Undiagnosed HIV (2019)
8
CDC. Estimated HIV incidence and prevalence in the United States 2015-2019.
HIV Surveillance Supplemental Report 2021
In U.S., 13% don’t
know their status
In SCAETC region,
17-20% don’t know
their status
9. Late-stage diagnosis is associated with more
morbidity and potential increased transmission
Natural history of HIV:
steady decline in CD4 count
Late-stage diagnosis (2017)
9
Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—
United States and 6 U.S. dependent areas, 2017. HIV Surveillance Supplemental Report. 2019;24(No. 3):1-74. Published June 2019
10. HIV Treatment is Prevention
10
Cohen, et al. NEJM 2011; 365: 493-505. Skarbinski J, et al. JAMA Intern Med 2015;175:588-96.
Bavinton BR, et al. Lancet HIV. 2018. IAS 2018 Conferencehttp://programme.aids2018.org/Abstract/Abstract/13470
11. HIV Screening Guidelines
CDC 2006
Test all pregnant women
Test all pts 13-64 yo
Test all pts with TB, STI
Test high risk patients at
least annually
USPTF 2013
• Test all 15-65 yo
• Test <15 & >65 yo if at risk
• Test all pregnant women
• Grade A recommendation
11
Branson BM, et al. MMWR 2006. Moyer, Virginia et al. Annals of Internal Medicine. 2013.
12. Status Neutral HIV Screening & Linkage to Care
Making HIV screening part of routine care helps ensure
patients are screened, despite presumed risk, and helps
reduce stigma
If HIV screen nonreactive/negative but significant risk,
linkage to HIV prevention (i.e. PEP, PrEP)
If HIV screen reactive/positive, linkage to HIV treatment
(antiretroviral therapy and holistic care)
12
13. HIV Transmission Risk
Not infectious:
Urine, saliva,
sweat, tears,
nasal secretions,
sputum, vomitus,
stool
13
https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html
Image: https://healthylife.werindia.com/your-road-to-healthy-life/hiv-is-not-transmitted-by
14. HIV Transmission Risk
Potentially infectious
fluids: blood, breast
milk, tissue, semen,
vaginal secretions,
visibly bloody fluids
Exposure across
mucosal surface, open
wound, or injection
14
https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html
15. HIV Treatment in Birthing Parent
Prevents Vertical Transmission
15
• Without antiretroviral therapy (ART)
• 40% if breastfeeding off ART
25%
• Birthing parent takes perinatal ART
• Labor ART +/- IV zidovudine (AZT)
• Neonate oral zidovudine (AZT)
<1%
16. PEP vs PrEP
HIV PEP = post-
exposure prophylaxis
Given after high-
risk exposure to reduce
risk of HIV infection
Start within 72 hours
of exposure
28-day course of oral
daily 3-drug regimen
HIV PrEP = pre-
exposure prophylaxis
Daily regimen
given before exposure to
reduce risk of HIV
infection
Oral 2-drug regimen or
long-acting injectable
medication
16
https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf
https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf
17. PrEP Coverage
17
CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance
data—United States and 6 dependent areas, 2019. HIV Surveillance Supplemental Report 2021
Nationally,
23% of the
people who are
considered at
considerable risk
of HIV infections
are receiving pre-
exposure
prophylaxis
18. 18
CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance
data—United States and 6 dependent areas, 2019. HIV Surveillance Supplemental Report 2021
19. PrEP Access is Improving
20 Urban areas in US
from 2014-2017
PrEP awareness among
MSM increased
PrEP use increased
Awareness Use
0
10
20
30
40
50
60
70
80
90
100
PrEP among MSM
2014 2017
Finlayson, E et al. MMWR July 12,2019. 68(27).
20. Need for PrEP to reach more people at risk
Continued disparities among
certain populations with
new HIV infections
and lack of access to HIV PrEP
Interventions to improve
metrics at each step
of
PrEP care Continuum
could reduce
disparities
Jenness, S et al. CROI2018. Abstract 1149
21. PrEP Uptake
Barriers
Poor access to health care in
the most at-risk communities
Competing priorities – housing,
transportation, employment
Limited risk awareness and HIV
prevention education among
many vulnerable populations
Provider preconceived notions
Solutions
Care navigation and Medicaid
expansion
Address social determinants of
health
Public education about risk and
harm reduction
Provider education and cultural
literacy
21
22. Resources
National Clinician Consultation
Center http://nccc.ucsf.edu/
HIV Management
Perinatal HIV
HIV PrEP
HIV PEP line
HCV Management
Substance Use Management
Present case on ECHO
https://echo.unm.edu/locations-2/ec
ho-hubs-superhubs-united-states/
AETC National HIV
Curriculum
https://aidsetc.org/nhc
AETC National Coordinating
Resource Center
https://targethiv.org/library/aet
c-national-coordinating-resou
rce-center-0
Additional trainings
[email protected]
www.scaetc.org
22
Editor's Notes
#1:Version date_12 2021
Target audience:
Medical providers (physicians, nurse practitioners, physician assistants, pharmacists, nurses, medical assistants)
Behavioral health providers
Case managers
Outreach workers
Dental professionals (dentists, hygienists, dental assistants)
Healthcare student learners
Clinic administrators
#3:Presenters – please add your relevant financial disclosures to this slide.
#4:Recognize the need for HIV screening and prevention (epidemiology, transmission risk, risk of progression of immunosuppression and immune dysregulation).
Recognize disparities in accessing HIV prevention and treatment (epidemiology and access to services).
Identify HIV screening guidelines (transmission risk without stigmatization) and explain why HIV screening is routine best practice.
Explain status neutral linkage to care.
#5:Trend in new infections from 2010 to 2019
40,000 ISH to 36,000 ISH. Slide Sets | Resource Library | HIV/AIDS | CDC: www.cdc.gov
Goal with EHE is 2025 – approximately 8000 to 9000 new infections; 2030 - <3000 new infections
2018 HIV Surveillance Report
The annual number of new diagnoses decreased 9% from 2010 to 2016 in the 50 states and the District of Columbia.
In 2018, gay, bisexual, and other men who have sex with men accounted for 69% of all new HIV diagnoses in the United States and 6 dependent areas. In the same year, heterosexuals made up 24% of all HIV diagnoses
From 2010 to 2017, HIV diagnoses decreased 10% among youth overall in the 50 states and the District of Columbia.
In 2018, youth aged 13 to 24a made up 21% (men: 92% MSM; women: 85% WSM, 12% IDU)
2019 surveillance report
The annual number of HIV infections in 2019, compared with 2010, increased among persons aged 25–34 years (35%), but decreased among persons aged 13–24 (−46%) and 45–54 years (−36%).
The annual number of HIV infections in 2019, compared with 2010, decreased among persons with infection attributed to heterosexual contact (−24%). The annual numbers remained stable among persons with infection attributed to injection drug use (IDU), male-to-male sexual contact (MMSC), and MMSC and IDU.
#6:2018 HIV Surveillance Report
The most affected subpopulation is African American gay and bisexual men (42% of new HIV diagnoses in 2018 with accounted for 13% of the US population)
Rates of Diagnoses of HIV Infection among Adults and Adolescents, by Age at Diagnosis, 2008–2012—U.S. 50,000 new patients infected with HIV/yr. http://www.cdc.gov/hiv/library/reports/surveillance/
37,600 new patients infected with HIV/yr in the U.S.2014
Highest increases in youth (13-25), MSM, racial minorities
Implies the need for alternatives/additions to condoms
Additional statistics about disparities
2 out of every 5 patients newly diagnosed with HIV are youth
African American MSM have 5x the national average of new HIV diagnoses. African Americans make up 12% of US population but 44% of new HIV diagnoses.
One of every 2 women newly infected with HIV is African American.
New HIV diagnoses in Native American population increased 19% between 2005 to 2014 & 63% in MSM
Transgender patients have 3x the national average of new HIV diagnoses
Hispanics make up 18% of US population but 25% of new HIV diagnoses.
2019 Surveillance report
In 2019, the largest percentage of HIV infections were attributed to MMSC (66%), followed by heterosexual contact (22%).
In 2019, Black/African American persons made up approximately 12% of the population of the United States but accounted for 41% of HIV infections. White persons made up 62% of the population of the United States but accounted for 25% of HIV infections. Hispanic/Latino persons made up 17% of the population of the United States but accounted for 29% of HIV infections.
The estimated HIV incidence for American Indian/Alaskan Native persons should be used with caution because the RSE is 30%–50% .
#7:PWH= people with HIV
13% don’t know their status (1 in 7.5 don’t know it)
36,801 new hiv dx in US and dependent areas in 2019.
Of those, 69% gay and bisexual men, 23% heterosexual, 7% IDU
Number highest among 25-34yo
Transgender people: 2% MTF, 1% FTM
86% male
Rates of Diagnoses of HIV Infection among Adults and Adolescents, by Age at Diagnosis, 2008–2012—U.S. 50,000 new patients infected with HIV/yr.
CDC. MMWR 2015;64:657-662 (2012 data).
Estimated 1 in 8 HIV-infected women in the U.S. do not know their status
-13% general US population- 44% of 13-24yo do not know
http://www.cdc.gov/hiv/library/reports/surveillance/
NM: We have roughly 3,300 persons living with HIV. And average 131 new infections per year. 119 in 2012 – 142 in 2013 – 129 in 2014, 133 in 2015 – 134 in 2016
CDC. MMWR 2015;64:657-662 (2012 data).
Estimated 1 in 8 HIV-infected women in the U.S. do not know their status
-13% general US population- 44% of 13-24yo do not know
http://www.cdc.gov/hiv/library/reports/surveillance/
#8:Estimated 13% of people in the US living with HIV infection are unaware of their diagnosis
Darker the color, the fewer the people with HIV have been diagnosed
HIV Screening is Important for Prevention & Treatment of HIV.
Those who don’t know their status thought to account for 30-50% of new infections (Marks, et al. 2006)
#9:2017 data
This means that patients have had undiagnosed HIV infections for about 10 years.
Stage 3 HIV: CD4<200 or CD4<14% or any CD4 with active opportunistic infection or malignancy
HIV Screening is Important for Treatment of HIV
21% new HIV diagnoses in the U.S. already have advanced disease (21% stage 3, 51% stage 2+3)
People who know they are infected can start HIV treatment
HIV treatment (HAART/ART) results in viral suppression and markedly reduced transmission1-3
Studies show the benefit of ART on all people with HIV (PWH)4,5
1. Cohen MS, et al. NEJM 2011;365:493-505. 2. Skarbinski J, et al. JAMA Intern Med 2015;175:588-96. 3. Rodger AJ et al. JAMA 2016;316(2):1-11. 4. Smith et al. JAIDS 2013; 63S2:S187-99. 5. Kitahata MM, et al. NEJM 2009;360:1815-26.
#11:STI= sexually transmitted infection
Branson BM, et al. MMWR Recomm Rep. 2006;55(RR-14):1-17.
Thought that those who don’t know their status account for 50% of new infections (Marks, et al. 2006)
Verbal consent for testing (written consent no longer needed)
https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis
#12:PEP=post-exposure prophylaxs; PrEP=pre-exposure prophylaxis
HIV Screening is Important for Prevention
Knowing they have HIV allows people to
Protect others from becoming infected
Make safer decisions about sex, needle use, & their health care
PWH who know their status avoid behaviors that spread infection
Those at high risk but test negative can utilize prevention strategies
Coates, et al JAMA 1987;258:1889. Doll et al. Health Psychol 1990;9:253-65. Fox, et al. AIDS 1987;1:241-6. Gibson, et al. AIDS and Behavior 1999;3:3-12. Rietmeijer, et al. AIDS 1996; 10:291-8. van Griensven et al. Am J Epidemiol
#13:Status neutral approach.
Screen all patients for HIV and all those with history sexual activity for STIs.
Inform all patients about HIV transmission risk – for their own use, to help spread reliable information to communities, to reduce spread of misinformation, to reduce stigma
#14:Risk reduction approach
Empower patients to make risk assessment and behavior decisions for themselves based on scientific information
Potentially infectious fluids also include visibly bloody fluids, other bodily fluids (cerebral spinal fluid, synovial fluid, pleural fluid, pericardial fluid, amniotic fluid)
Higher risk: Receptive anal sex (Per episode: 0.3 - 3%), Needle sharing (Per episode: 0.67%)
Lower risk: Oral sex (Per episode: 0.06%) Insertive sex (Per episode 0.03 – 0.14%)
1. Bell DM. Am J Med 1997;102(suppl5B):9--15. 2. Ippolito G et al. Arch Int Med 1993;153:1451--8. 3. Am J Epi 1999; 150:306-11.4. Am J Epi 1999;150:306-11.5. MMWR 47;RR-17, 1998.6. NEJM 336(15):1072-8. 7. Am J Epi 1999;150:306-11.8. Rothenberg RB et al. AIDS 1998;12:2095-2105.9. MMWR 47;RR-17, 1998.10. ACTG 076
#15:Higher rate in Asia and Africa (25-40%): other medical conditions, prolonged breastfeeding
1999 study of 57 woman who had viral loads <1000 at delivery, none had hiv infected babies (irrespective if on haart or not)
Plasma viremia is significant risk: rate of vertical transmission 3.4 gold higher per log of plasma viremia.
Give AZT even if resistance: crosses placenta readily, reduces genital viral load
#17:CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2019. HIV Surveillance Supplemental Report 2021
Nationally, rates of PrEP use are around 23%, which is to say that 23% of the people who are considered at considerable risk of HIV infections are receiving pre-exposure prophylaxis
#18:People of color comprise a disproportionate number of new HIV infections in the US, yet have limited uptake of PrEP
PrEP has been most widely adopted by college educated, middle-aged, white gay men
Many LGBTQ+ community centers across the US are based in neighborhoods most popular for white gay men
If we look at it from a gender perspective, Men have at least 3x higher PrEP coverage than woman
Black heterosexual woman have higher rates of HIV acquisition than other women
CDC, 2016
Though 20% of the US population, Latinx people account for ¼ of new cases of HIV. Most of those diagnosed are men
Awareness of PrEP is low among Latinx individuals at risk, particularly MSM, posing challenges to adoption
Stigma or fear of being judged for one’s behaviors may serve as a barrier to PrEP adoption, as well as linguistic and economic access to resources in some regions
#19:Finlayson, T et al. Changes In HIV PrEP Awareness and Use among MSM – 20 urban areas, 2014 and 2017. MMWR, 7/12/19.
PrEP awareness among MSM increased from 60% to 90%
PrEP use increased from 6% to 35%
#20:-Jenness, S et al. CROI2018. The PrEP care continuum and HIV racial disparities among MSM. Abstract 1149. Mathematical model of HIV transmission for MSM to include race-stratefied transitions through PrEP continuing from awareness to access to rx to adherence to retention.
https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6827-H.pdf
#22:Find an HIV-related topic TeleECHO in your area: https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/
IDEA Platform: Infectious Diseases Education & Assessment. https://idea.medicine.uw.edu/
AETC National HIV Curriculum: 6 core modules for self study; regularly updated; CME, CNE
Hepatitis C Online Curriculum: https://www.hepatitisc.uw.edu/
Hepatitis B Online Curriculum: https://www.hepatitisb.uw.edu/
National STD Curriculum: https://www.std.uw.edu/
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