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Kevin A. Fenton , MD, PhD, FFPH Director

The 4 th Decade of HIV in the United States: Urgency , Focus, Action. Kevin A. Fenton , MD, PhD, FFPH Director National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention Centers for Disease Control and Prevention. AIDS 2012 North America Regional Session July 25, 2012.

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Kevin A. Fenton , MD, PhD, FFPH Director

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  1. The 4th Decade of HIV in the United States: Urgency, Focus, Action Kevin A. Fenton, MD, PhD, FFPH Director National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention Centers for Disease Control and Prevention AIDS 2012 North America Regional Session July 25, 2012

  2. “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance will have unfettered access to high quality, life-extending care, free from stigma and discrimination.” United States National HIV/AIDS Strategy, July 2010

  3. Overview • HIV in the U.S. today: New realities, urgent threats of the epidemic burden and trajectory • A Tale of Many Cities: Geographic concentration of HIV/AIDS in the United States • Moving upstream: The social, structural and health system determinants of HIV/AIDS in the United States • Enhancing prevention: New directions for achieving an AIDS-free Generation

  4. 1. HIV/AIDS in the U.S. TodayTrends in HIV Prevalence and Incidence, United States SUMMARY • An estimated 1.1 million people in the United States living with HIV • Approximately 50,000 Americans infected and 18,000 deaths annually • HIV prevalence increased by 8% from 2006 to 2009 • HIV transmission rate has declined 9% from 2006 to 2009 Hall JAMA 2008; Prejean PlosOne2011; HIV Surveillance Supplemental Report 2012; Holtgrave et al., JAIDS.

  5. Estimated Number of Adults and Adolescents Living with HIV Infection (Diagnosed and Undiagnosed)* and Percent Undiagnosed† – United States, 1985 - 2008 *HIV prevalence was estimated based on national HIV surveillance data for adults and adolescents (aged ≥ 13 years at diagnosis) reported through June 2010 using extended back-calculation. †The number of undiagnosed HIV infections was derived by subtracting the estimated number of diagnosed living cases from the estimated overall HIV prevalence

  6. HIV Incidence by Transmission Category, United States, 1980-2009 • SUMMARY • Overall HIV incidence stable for the past decade • HIV incidence in IDUs has declined by >80% since peak in the 1980s • All groups showing declines in HIV incidence except MSM • Among MSM incidence has doubled since nadir in early 1990s • HIV incidence increased significantly in young Black MSM (50%) between 2006-2009 CDC: HIV Prevention Progress to Date, June 2012; Prejean PlosOne; 2011 MMWR 58 (46).

  7. HIV Health InequitiesHIV incidence by gender and race/ethnicity SUMMARY • In 2009, the rate of new HIV infection for black men was more than 6x as high as that of white men, and 2.5x as high as that of Latino men or black women. • In 2009 there were 11,200 (23%) new HIV infections among US women. • The rate of new HIV infections among black women was 15x that of white women, and over 3x the rate of Hispanic/Latina women • 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV Prejean, PlosOne 2011; CDC, HIV Surveillance Report 2010; CDC, HIV among Women, August 2011; MMWR 59 (40).

  8. HIV Health InequitiesHIV incidence in most affected subpopulations N= 48,100 (42,200-54,000) • SUMMARY • MSM account for 2% of the US population but 64% of new HIV infections • Black MSM account for 73% of infections in Black men and 38% of MSM infections • In 2009, Latino MSM accounted for 81% (6,000) of new HIV infections among all Latino men and 20% among all MSM Prejean PlosOne2011; Purcell Open AIDS, 2012; MMWR 59 (37); CDC, Estimates of New HIV Infection, 2006-2009.

  9. HIV Health InequitiesHIV incidence in men who have sex with men SUMMARY • About 39% (or 19,000) of Americans infected in 2009 are 13 to 29 years old • Young MSM accounted for 27% of new HIV infections in the US and 69% of new HIV infections among persons aged 13–29. • Among MSM aged 13 to 24 diagnosed with HIV in 2010, 58% were Black • Also, black MSM experienced the largest increase among young MSM in diagnosed HIV infections—from 2,925 diagnoses in 2007 to 4,358 diagnoses in 2010 Prejean PlosOne2011; CDC HIV surveillance Report, 2010.

  10. 2. A Tale of Many CitiesDistribution of reported AIDS cases in the United States, 2009 SUMMARY • By region, the number of people diagnosed with AIDS is highest in the South (14,722 in 2010), followed by the Northeast (7,824), the West (6,292), and the Midwest (4,178) • AIDS diagnosis rate is highest in the Northeast (14.2) followed by the South (13.0), West (8.8) and Midwest (6.3). • Midwest is only region in which rates have increased in recent years. CDC, HIV Surveillance Report 2010.

  11. Rates of Diagnoses of HIV infections among Adults and Adolescents, 2010—46 States and 5 U.S. Dependent Areas SUMMARY Of the 46 states with long-term confidential reporting: • Four states account for an estimated 50% of persons living with a diagnosis of HIV infection at the end of 2009: New York, California, Florida and Texas • Ten states account for an estimated 73% of persons living with a diagnosis of HIV infection at the end of 2009: New York, California, Florida, Texas, New Jersey, Georgia, Illinois, Pennsylvania, North Carolina and Virginia

  12. Rates of diagnoses of HIV infection by MSA of residence, 2010 – 46 states and Puerto Rico SUMMARY • Most peoplediagnosed with AIDS in 2010 reside in areas of >500,000 persons • Among MSAs in the 50 states and DC, the top 10 MSAs accounted for an estimated 55% of persons living with a diagnosis of HIV at the end of 2009: New York, Miami, Los Angeles, Chicago, Atlanta, San Francisco, Houston, Philadelphia, Dallas and Baltimore (unadjusted data)

  13. Rates of Persons Living with HIV or AIDS Diagnosis, by Zip Code, 2009 Los Angeles New York City Philadelphia Washington D.C.

  14. Material circumstances Social cohesion Psychosocial factors Behaviours Biological factors 3. Moving UpstreamAdapting the WHO SDH Model to understand HIV Inequalities HIV/STI Prevalence Socioeconomic & political context Governance Policy (Macroeconomic, Social, Health) Cultural and societal norms and values Sexual/IDU Networks Homelessness Racism, Sexism Social Position Education Occupation Income Gender Ethnicity/Race   Distribution of health and well-being Residential segregation   Women’s empowerment   Sexual/DU risk and mixing  Trans- Homo-phobia Sexual orientation Migration Status Health Care System Social Determinants of Health and Health Inequities Correctional System

  15. Addressing Social DeterminantsSocial and Economic Inequities Impact HIV Rates Age-adjusted percentage of persons with no health insurance coverage, by race/ethnicity, 2011 SUMMARY • Nearly one quarter of African American and Latinos families live in poverty, compared to 10 percent of white families (U.S. Census Bureau, 2010) • Substantial differences in health insurance coverage, by race/ethnicity • CDC study found HIV diagnosis rates increase as income inequality and proportion of unmarried increased (Gant et al., 2012) Source: CDC/NCHS, National Health Interview Survey, 2011

  16. Addressing Social DeterminantsHIV in Impoverished Urban Areas of United States • SUMMARY • 2.1% of heterosexuals in high-poverty urban U.S. areas infected with HIV • Poverty is most important for HIV among inner-city heterosexuals • No differences found in HIV prevalence by race/ethnicity in this population • Inner-city HIV prevalence also associated with homelessness, unemployment, lower educational attainment MMWR, 60 (31)

  17. Percentage of People Who Have Ever Been Tested, Overall and by Population, 2008 • SUMMARY • In 2009, 45% of adults 18-64 had ever been tested for HIV and 9.6% of adults HIV tested in the past 12 months (range: 4.9%–29.8%) • In 2009 37% of the 45,336 new diagnoses developed AIDS within a year of diagnosis • Among people diagnosed with HIV in 2009, older adults (over 45), male injection drug users, Hispanic/Latinos, and people of multiple races had higher proportions of late diagnosis CDC, HIV Surveillance Report 2010; MMWR Vital Signs 2010.

  18. The Continuum of HIV Prevention, Care and Treatment in the United States, 2010 MMWR, 60 (47), 2011 • SUMMARY • Of the estimated 942,000 persons with HIV who were aware of their infection, approx. 77% were linked to care, and 51% remained in care • In care, 45% had prevention counseling; 89% given ART; 77% virally suppressed • Estimated 28% of all HIV-infected persons have a suppressed viral load

  19. 4. Enhancing Prevention CDC’s role in National AIDS StrategyImplementation • Three goals for the NHAS: • Reducing HIV incidence • Increasing access to care and optimizing health outcomes • Reducing HIV-related health disparities • CDC HIV prevention aligned with NHAS Goals: • The lead federal agency for domestic HIV prevention (Goal1) • Collaborates with HRSA to improve care (Goal2) • Implements programs and data systems to reduce and monitor disparities (Goal3) • Actively coordinates efforts with other HHS agencies (Goal 4) • In addition, CDC systems are used to measure progress on most NHAS indicators

  20. Enhancing PreventionHigh-Impact Prevention • Ensuring that the right interventions are selected, targeted and scaled • Key components • Effectiveness and cost • Feasibility of full-scale implementation • Coverage of targeted population • Interaction and targeting • Prioritizing • Preventing the most HIV and promoting equity Available for download at: www.cdc.gov/hiv

  21. Enhancing PreventionHigh Impact Prevention in Practice • HIV Testing • Testing in health care and non-health care settings • Testing of pregnant women • Ensure linkage to care and prevention services • ART and adherence interventions • STD screening and treatment • Partner services • Behavioral interventions for HIV-positive persons • Retention and re-engagement in care • HIV Prevention with Positives Condom Distribution • Focus on people with HIV and at high risk • Structural and Policy Initiatives • Create enabling environment for optimal HIV prevention and care through policies, regulations, and practice

  22. Summary • More Americans are living with HIV with stable incidence, declining mortality and declining transmission rates • The U.S. HIV epidemic is demographically and geographically concentrated at a time when one in five are unaware of their status and less than a third are engaged in care and maximally benefitting from ARTs • Future success will depend on our ability to implement and bring to scale what we know works, for those at risk, while expanding the knowledge base for more effective implementation

  23. Acknowledgements • Jonathan Mermin • Amy Lansky • Irene Hall • Eva Margolies • Sara Bingham

  24. Thank You Kevin A. Fenton, MD, PhD, FFPH Centers for Disease Control and Prevention 404-639-8000 Email: kif2@cdc.gov Twitter: CDC_DrFenton Web: www.cdc.gov/nchhstp

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