Evolving HIV epidemic by 68S6jf

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									Evolving HIV epidemic/endemic
• Early epidemic         • 2008 SF endemic
  – No effective           – Very effective
    treatments               treatments
  – High level of          – High level of
    discrimination           discrimination
  – Fear                   – Fear
  – Limited government     – Limited government
    response                 response
               The four T’s
•   Treatment
•   Testing
•   Tracing (Tracking)
•   Transmission
Viral load and risk of transmission




                   Quinn et. al, NEJM 2000
    What do we know reduces HIV
             infections?
•   Condoms
•   Perinatal ART
•   Needle exchange/syringe access
•   Lower viral loads
•   Circumcision
  What do we know lowers HIV
        risk behavior?
• Counseling
• Getting a positive HIV test
• Stopping substance use
  What do we think lowers HIV
            risk?
• STD treatment (Strong evidence)
• PEP (Supportive evidence)
• Improving SES, social support (Supportive
  evidence)
• Seroadaptation (Suggestive evidence)
• Reducing substance use (Suggestive
  evidence)
         Spectrum of prevention
          (from 2004 SF Plan)
•   Individual
•   Community
•   Individual prevention provider
•   Community of prevention providers
•   Structural barriers
•   Policy and legislation
       Behavioral interventions
             challenges
• Do they work?
  – Most show some reduction in sexual risk
    behavior
  – We don’t know what reduction is necessary to
    actually reduce HIV
  – Large selection bias in RCTs
Brief CBT has an effect in reducing
       sexual risk behavior…
Mean reduction in number of episodes of unprotected anal intercourse (UA)
with non-primary partners of HIV-positive or unknown serostatus, in the
preceding 90 days, by study arm (Dilley, JAIDS, 2005).

           0
                                                                                         6 months
         -0.5
           -1
        -1.5                                                                             12 months
          -2
        -2.5
           3
        -3.5
                 Control      Diary    Self-justification   Self-justification + diary
                   A1          A2             B1                        B2
                           Project RESPECT Results*:
                       HIV Prevention Counseling Effective
                     250
 New STD diagnoses




                     225                                         211
                     200
                                                          173
                     175             149
                     150
                     125      107
                     100
                      75
                      50
                      25
                       0
                              6 months*                   12 months*

                                           RESPECT   Control     (*p<0.05)

Kamb, M.L., et al., JAMA, 1998
                EXPLORE study
• 4295 high-risk HIV-negative MSM enrolled in
  behavioral trial (10 sessions vs. RESPECT),
  followed a mean of 3.25 years
• Risk behavior change: Significant reduction (13-
  22%) over long period of follow-up
• No significant reduction in HIV seroincidence
  – Unadjusted analysis: intervention reduced HIV infections by 18.2%
    (95% CI -4.7%-36%)
  – Adjusted analysis: intervention reduced HIV infections by 15.7% (95%
    CI -8.4%-34.4%).
        Behavioral interventions
              challenges
• Many are time-intensive
• Most are expensive
  – Feasibility, sustainability
• Limited data on effectiveness on reducing risk
  – Difficult to measure
• Consider focus on brief and/or targeted
  interventions that emphasize infection detection,
  linkage to care, and addressing risk cofactors
  driving HIV
        Awareness of serostatus among
        people with HIV and estimates of
                  transmission
                        Accounting for:
  ~25%
unaware
    of                                               ~54%
infection                                            of new
                                                   infections

                                                       Marks, et al
   ~75%                                                AIDS 2006;20:1447-50
 aware of
 infection
                                                     ~46%
                                                     of new
                                                   infections


     People Living with             New Sexual Infections
 HIV/AIDS: 1,039,000-1,185,000       Each Year: ~32,000
Impact of routine HIV testing in SF

• May 2006 SFDPH updated policy to
  allow for non-written patient consent for
  HIV testing at SFGH/COPC
• Requires physician documentation of
  consent in chart
• Evaluated impact of that administrative
  change on HIV testing and HIV case
  identification with time-series analysis
                                 From Jeff Klausner
 Beyond routine rapid testing

• Increase HIV case-detection
  – HIV RNA screening
  – Disclosure and partner services
• Assure new cases enter care
• Support reduction in HIV transmission in
  care
  – Counseling
  – Substance use treatment
  – STD treatment
  – HAART                      Adapted from Jeff Klausner
       Acute infection and prevention

• Short term risk reduction may have high impact
   – 43% of all heterosexually transmitted HIV infections
     in Rakai, Uganda attributable to first 2.5 months of
     infection (Wawer MJ, JID 2005)
• Acute infections can provide an opening to access real
  sexual networks that contain active HIV transmission
• Can RNA testing be used as a public health tool to
  detect acute infections?



                                              From Chris Pilcher
               Resolution testing
                               A



                 Individual
               testing on 10
                 specimens


                 10 pools of
                10 screened

20 Screening
Pools Tested
    N=2000                          From Chris Pilcher
 HIV testing and RNA screening
      SF City Clinic, 2003-2006

• 10,200 persons tested
  – 317 (3.2%) HIV Ab positive
  – 9883 HIV Ab negative
    • 34 (.34%) RNA positive
    • 11% increase in HIV case detection
    • All confirmed



                       Klausner et al. IDSA 2004; NEJM 2005
Partner notification outcomes
             N=202
        9%

                    26%
                           Prior HIV+
                           New HIV+
                           HIV-
  34%                      UTL
                      9%   Refused




              22%
                                     From Klausner
 Moving HIV Prevention forward…
• Multiple stakeholders
• Consensus process
• Balance of community input, science, politics,
  and funding realities
• Priority setting: by definition, cannot do
  everything for everyone

Change function of
  Desire for change x Clarity of Vision x Clarity of next steps
           Partnership in Community Planning

•   Community planning is a concept that
    began in SF in response to the
    HIV/AIDS epidemic. It is built on a
    model of partnership between the
    federal government, local health
    department and community
    participation.
•   For more than 13 years San Francisco
    has played a role in redefining the way
    in which public health and the medical
    community respond to HIV
•   Community planning is a process that
    is based on the concept that the best
    way to respond to the HIV epidemic is
    through local decision making.




                                               22
The Community Planning Cycle

           a) Epidemiologic           b) Priority-
                Profile                 Setting




       e) Letter of                      c) HIV Prevention
      Concurrence                               Plan


                         d) Health
                        Department
                        Application
                          to CDC


                                                             23
    Happy to discuss more…
• Grant Colfax, MD
  Director of HIV Prevention and Research
  San Francisco Department of Public
  Health
  Grant.Colfax@sfdp.org
  (415)-554-9173

								
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