# Presentation: 558645

## Update on the HIV/AIDS Epidemic in the United States

**Robert S. Janssen, MD**
**Director, Divisions of HIV/AIDS Prevention**
**National Center for HIV, STD, TB Prevention**
**Centers for Disease Control and Prevention**
**November 9, 2004**

## Incidence and Prevalence

- _Incidence_ – the number of new HIV infections  occurring each year
- _Prevalence_ – the total number of people living with HIV or AIDS each year

## Estimated Number of New HIV Infections

**Estimated Number of New HIV Infections**
**Annually, United States**

## Current Status of Implementation ofHIV (without AIDS) ReportingOctober, 2004

**Name-Based**

**Name-to-code **

**Code-Based**

**Other **

- Washington, D.C.

**Notes:**
Patient identifier used in surveillance
36 states + VI, Guam, PR: name
8 states + DC: code (Kentucky converting to name in October, 2004) 
5 states: name-to-code
2 states combination of name/code or name/no name
Philadelphia to started coded reporting in April 2004, 
14 codes in 15 areas

## Annual Number of HIV/AIDS Cases, by Transmission Category, 32 States, 2000-2002

**Note: Estimates are adjusted for reporting delays and redistribution of transmission category **
**for cases without risk factor information.  Confidence intervals are indicated by broken lines.**

**Men who had sex with men (MSM)**

**High-risk heterosexual contact**

**Injection drug use (IDU)**

**MSM / IDU**

**Notes:**
The annual number of cases has increased among men who had sex with men but did not inject drugs, 
and decreased slightly in other transmission categories.  

## Deaths

**Annual Numbers of ****AIDS Cases****, ****Deaths of Persons with AIDS****, and Persons Living with AIDS, United States (including US Territories), 1985-2002**

**Note: Estimates are adjusted for reporting delays**

**Deaths**

**Persons living with AIDS**

**AIDS Cases**

- Beginning of  HAART

- 1993 Definition implementation

**Notes:**
The annual number of AIDS cases peaked in 1993, when the surveillance case definition for AIDS was expanded.  
This peak is thought to have resulted in part from a backlog of cases meeting the new criteria of the case definition that may actually have been diagnosed earlier but were reported to have been diagnosed in 1993.  
Thus, the declines in 1994 and 1995 were expected as the surveillance system adapted to the new case definition.  
The steeper decreases in 1996 and 1997, however, are thought to be due to the effects of highly active antiretroviral therapy (or HAART), which began to be widely used in 1996.  
After 1998, the annual number of AIDS cases has been level.
Trends in the annual number of deaths of persons with AIDS followed a somewhat similar pattern, peaking in 1995, then steeply decreasing in 1996 and 1997, coinciding with the spread of the use of HAART, and finally being level from 1998 through 2002.  

The annual number of persons living with AIDS was calculated as the difference between the annual cumulative number of cases diagnosed and the annual cumulative number of deaths.  It has steadily increased every year since the early 1980s.  

## Trends in HIV/AIDS

- _Incidence_ – stable or possibly increasing in some groups
- _Prevalence_ – constantly increasing

## Strategies of CDC’s Advancing HIV Prevention Initiative

- Make voluntary HIV testing a routine part of  medical care
- Implement new models for diagnosing HIV infections outside medical settings
- Prevent new infections by working with persons diagnosed with HIV and their partners
- Further decrease perinatal HIV transmission

**Notes:**
And that’s why one of the four key strategies in the Advancing HIV Prevention Initiative is preventing new infections by working with persons diagnosed with HIV and their partners.  PCRS – including partner notification – is an important part of this strategy, because it’s an effective way to identify HIV-infected persons not yet aware of their infection and link them to medical, prevention, and other services as soon as possible after they become infected.

## Awareness of Serostatus among Persons with HIV

- Number HIV infected              	850,000 - 950,000
- Number unaware of their
- HIV infection  			180,000 - 280,000** **

**Awareness of Serostatus ****among Persons with HIV**

- Source: Fleming, 9th CROI, 2002; CDC unpublished data

**Notes:**
At the same time, the number of people living with HIV continues to increase and of the estimated 850,000 to 950,000 people living with HIV today in the United States, an estimated 25% or 180,000 to 280,000 HIV-positive individuals are unaware of their serostatus (1).  These are obviously people who may unwittingly be transmitting the virus.

## Awareness of Serostatus Among People with HIV and Estimates of Transmission

- ~25% Unaware of Infection

- ~75% Aware of Infection

- People Living with HIV/AIDS: 850,000-950,000

- New Infections Each Year: ~40,000

- Accounting for:

- ~55%      of New Infections

- ~45%      of New Infections

**Notes:**
Currently, in the United States, there are an estimated 850,000-950,000 people who are infected with HIV. Of those, the majority of people, an estimated 670,000-770,000 – or 75% – are aware of their status. 

But that leaves 25% – or 180,000 to 280,000 people – unaware they are infected with HIV. 

It has been estimated that infections transmitted from this group account for 27,000, or 2/3, of the 40,000 new infections per year. 

The importance of getting these individuals tested and into treatment that includes prevention interventions is critical.

## Late TestingSurveillance Data 2000-2003

**70,233 persons diagnosed with HIV**
**25,986 (37%) developed AIDS within a year after HIV-positive test**

- Source: Kamimoto, 11th CROI, 2004

## Approaches for DiagnosingMore Infections

**Increase diagnoses in current venues**
- New venues
- New technologies

## Number of HIV Tests Reported from CDC-funded Sites, United States, 1992-2002  

- Number of HIV Tests Reported from CDC-funded Sites, United States, 1992-2002

## Number of HIV-positive Test Results Reported from CDC-funded Sites, United States, 1992-2002  

- Source: Counseling and Testing System (Summary Record Data), 1992-2002, CDC.

## Percentage of Total HIV Tests and Total HIV-positive Test Results by Site Type, CDC-funded Sites, United States, 2002

- Percentage

- Site Type

- C&T sites

- STD clinic

- Drug treatment facility

- Family planning clinic

- Prenatal/OB clinic

- TB clinic

- Other health dept.

- Prison

- Private MD/Clinic

- Other

## Approaches for DiagnosingMore Infections

**Increase diagnoses in current venues **
**New venues**
**New technologies**

## 2003-05 AHP Demonstration Projects

- Purpose:
- Develop models and demonstrate feasibility of implementing AHP strategies
- Seven demonstration projects funded in 2003 in 32 sites: 9 health departments, 17 CBOs, 6 university-based medical providers
- Total $23 million for 2 years

**Notes:**
The purpose of the demonstration projects is to develop models for immediate deployment to demonstrate the feasibility for implementing AHP strategies in the future.

The seven demonstration projects funded in 2003 for two years will test the feasibility of the strategies and will provide detailed information that will be used widely to implement the strategies of this initiative.

There are three state and local Health Department projects with a total of 9 awards;
Three CBO projects with a total of 17 awards using MAI (Minority AIDS Initiative funds;
One Prevention in Medical Care project with a total of 6 awards;

A total of 23 million dollars was awarded in contracts for this two year period.

## 2003-05 AHP Demonstration Projects(HIV Testing)

- Routine HIV testing in medical settings
- Rapid HIV testing in jails
- Rapid HIV testing in non-medical settings
- Partner counseling and referral using rapid HIV tests
- Working with social networks

**Notes:**
$23 million

## 2003-05 AHP Demonstration Projects 

|  | Routine Testing in Medical Settings | RT in Jails | RT in non-Medical Settings | PCRS w/RT | Social 
Networks |
| --- | --- | --- | --- | --- | --- |
| Total Orgs Funded | 4 HDs | 4 HDs | 7 CBOs | 6 HDs | 9 CBOs |
| Total Number Tested | 3657 | 7497 | 4440 | 80 | 871 |
| Total Positives (seroprevelance) | 31 
(<1%) | 150
(2%) | 74 
(2%) | 12 (15%) | 53 new pos.
(6%) |
| Total Positives Linked to Care | * | * | * | * | 44 |

- *Data currently unavailable

## Making HIV Testing a Routine Part of Medical Care

- Cook County Hospital Emergency Department (ED), Chicago, Illinois
- OraQuick testing since October 02
- 62% accept HIV testing
- 98% receive test results
- 3,802 patients screened
- 93 (2.4%) new HIV positive
- 80% entered HIV care        (median 18 days)
- HIV tests ordered by ED providers increased from 5 to 29 per month

## Approaches for DiagnosingMore Infections

**Increase diagnoses in current venues **
**New venues**
**New technologies**

## Three FDA-approved Rapid HIV Tests

|  | Sensitivity
(95% C.I.) | Specificity
(95% C.I.) |
| --- | --- | --- |
| OraQuick 
Advantage HIV 1/2
- oral fluid | 99.6
(98.5 – 99.9)
99.3
(98.4 - 99.7) | 100
(99.7 – 100)
99.8
(99.6 – 99.9) |
| Reveal G2 | 99.8
(99.2 – 100) | 99.1
(98.8 – 99.4) |
| Uni-Gold Recombigen | 100
(99.5 – 100) | 99.7
(99.0 – 100) |

## OraQuick Procurement & Distribution

** **250,000 test kits shipped in 2003 (6-month shelf life)
-  167 shipments to 108 health departments and 	CBOs in 36 states
-  September – November 2003:
-  	22,811 persons tested
-  	334 (1.4%) HIV positive
-  105,200 test kits shipped in 2004
-   85 shipments to 73 health departments and CBOs
-         in 22 states

## Total Number of HIV Tests and % Post-test Counseled, by Test Type, HIV Status, and PMS-1 Project Area 

**	****Conventional Tests (2002)**

**	****Positive**

**Rapid Tests (2003)**

**	****Positive****	**

**	****Negative****	**

**n     (%)**

**n    (%)**

**n     (%)**

**n   (%) **

**	****Project Area****	****	**

**Michigan****	**** 5449  (52)       37   (76)               1251 (100)      15 (100)**

**New York****	**** 3702  (84)       51   (74)               4555  (99)       37  (81)**

**Utah****	****	****   662  (79)         3  (100)                922  (97)         9 (100)**

**Wisconsin         1909  (71)       19   (74)               1012  (98)       20  (80)**

**Total                 11722  (67)     110   (75)               7740  (99)       81  (86)**

**	****Negative ****	**

## Yield of Routine, Voluntary Inpatient Testing in an Inner-City Boston Hospital

**“****Think HIV” voluntary testing offered to all medical patients**
**Inpatients tested for HIV:**
** ****before program: 9.3 per month**
** ****after program:  33.8 per month**
**Mean monthly number of positive results:**
** ****before program:  1.3 per month**
** ****after program:  2.3 per month**
**Authors suggest that the same program in 72 U.S.   ****hospitals with similar patient profiles would identify       an additional 8,000-31,800 infected persons annually **

- (Walensky et al., Arch Intern Med 2002; 162:887-892)

## CDC Training for Rapid Tests 

**Rapid Test Training includes:**
**performing the OraQuick test**
**counseling for rapid testing**
**biohazard safety**
**Phase I (FY03): **
**14 Laboratory Trainers trained**
**388 providers trained**
**Phase II (FY04):**
**22 SAMHSA Counseling Trainers trained,**
**624 providers trained (44 of them were SAMHSA grantees in  demonstration projects in Methadone Treatment Centers)**
**Rapid Testing web site: 7,000-9,000 requests per month**

**Notes:**
Time it takes to train a person; evaluation of their ability to perform the test accurately after the training
The training is a three day course (approximately 6 hours of instruction time per day, with additional hours for persons needing extra practice in the areas of: performing a fingerstick, conducting test and/or interpreting results)

How do we evaluate their ability to perform the test accurately after the training?
During the training we evaluate the proficiency of skills demonstrated by participants via a checklist of step by step skill sets for (fingerstick, conducting/interpreting the test and health education/counseling messages) 
At this time we have not developed a mechanism to evaluate participant’s proficiency once they returned to their agencies to implement RT.  Perhaps we will need to collaborate with PPB POs to develop such an instrument or protocol 

What is the capacity of CDC and others to provide training to those who need it?
22 Counseling Trainers from SAMHSA have been trained to teach this course to SAMHSA grantees.  SAMHSA has been providing training using these trainers and the cadre of Laboratory Trainers trained by CDC.  (Additional information should be available from SAMHSA or Raul Romaguera) 
Presently only CDC has the capacity to teach the course.  CDC has engaged a contractor to take existing training materials and format them into a curriculum package that can be diffused nationally 
Once the TOT curriculum is completed, Health Departments and other national training partners will be provided with materials and opportunities to learn how to teach this course (CDC is currently planning Train-the-Trainer sessions for the course) 

## Prevention with Positives:Programs and Interventions

## North Carolina 2001

**Partners**
**elicited**

**173**
**Unable to**
**notify**

**592**
**Previously**
**HIV tested**

**767 Not**
**previously**
**HIV tested**

**404**
**Previously**
**tested HIV+**

**188**
**Previously**
**tested HIV-**

**279 Not**
**tested after**
**PCTRS**

**488 Tested**
**after PCTRS**

**122 Tested**
**after PCTRS**

**66 Not tested**
**after PCTRS**

**380**
**HIV-**

**108 (22%)**
**HIV+**

**17 (14%)**
**HIV+**

**105**
**HIV-**

**North Carolina 2001**

**1379**
**HIV+ persons**
**interviewed**

## Slide 29

**Notes:**
Last July, CDC published recommendations developed in collaboration with HRSA, NIH and the HIV Medicine Association of the Infectious Diseases Society of America.

These recommendations present strategies to incorporate HIV prevention into the medical care of persons living with HIV.  The recommendations are general and apply to all HIV-infected adolescents and adults, regardless of age, sex, race or ethnicity.  

They are intended for all persons who provide care to HIV-infected persons, including physicians, nurse practitioners, nurses, physicians assistants, social workers, case managers, and others.

MAIN ELEMENTS OF MMWR
*Risk screening
*Behavioral interventions
*Partner counseling and referral services

## Key Recommendations

- Screening
- Risk behaviors
- STDs
- Pregnancy
- Prevention messages & counseling
- Partner notification

## 2003-05 AHP Demonstration Project:Prevention in Care Settings (PICS) 

|  |  |
| --- | --- |
| Total Sites Funded | 6 
  |
| Number enrolled | 1057 |
| Provider Training Completed  | Six sites |

## “Americans should be proud that their country is now fully engaged in the global fight against HIV/AIDS.  At the same time, however, we must ask ourselves why we, collectively, don’t care more about the domestic epidemic.  Thousands of young Americans are dying each year of a preventable infection.”

-                             Harold Jaffe
- 			*Science *2004;305:1243