HIV Research Topics May 8, 2013 Michael Lowe, PhD, MSPH Adjunct Professor, DFPM

Disclaimer The opinions expressed in this presentation are my own personal opinions and do not represent in anyway the views of the Centers for Disease Control and Prevention. I am not officially representing this organization.

OUTLINE Current HIV Climate General Principles HIV Testing and Medical Care Providers Treatment Cascade Emerging Issues

Changing Epidemic – The First 20 Years

AIDS 2012 Conference -- BIG Names

OUTLINE Current HIV Climate General Principles HIV Testing and Medical Care Providers Treatment Cascade Emerging Issues

Field of HIV Research

OUTLINE Current HIV Climate General Principles HIV Testing and Medical Care Providers Treatment Cascade Emerging Issues

HIV Testing Background Centers for Disease Control and Prevention (CDC) estimated 1.2 million people living with HIV infection in the U.S.1 Men who have sex with men (MSM) are estimated to make up 2% of the U.S. population yet comprise 53% of the new HIV infections. 2 Early identification of HIV is beneficial for individual health-related outcomes and community prevention. 3,4 Approximately 20% of HIV+ people do not know they are positive. 1 Estimated 51% of new infections due to persons unaware of HIV status.

BACKGROUND HIV TESTING In 2006, CDC recommended routine HIV testing in health care settings 5 Universal screening for everyone Annual screening for persons at high risk for HIV Estimated 51% of new infections due to persons unaware of HIV status.

Gay Utah Survey (GUS), 2008 Participant Requirements: male; 18 years or older; Utah resident; gay, bisexual, or have had sex with a man 986 participants 57 HIV positive persons (only 1 person out of care) 60% overall had medical provider

Has a Medical Care Provider, n (%) Demographic Characteristics of Participants in GUS by having a Medical Provider within Last Year (873 Respondents) Characteristic Has a Medical Care Provider, n (%) Total 523 (60%) 873 Race/Ethnicity** White, non-Hispanic 432 (62%) 695 Hispanic 42 (46%) 92 Other 49 (57%) 86 Injection Drug Use (IDU) in last 6 months** IDU 13 (41%) 32 No IDU 510 (61%) 841 Ever Tested for HIV 435 (62%) 698 ** Statistically significant at a p value < 0.05

Sexual orientation in GUS Gay 804 (82%) Bisexual 109 (11%) Heterosexual* 10 (1%) Other** 60 (7%) 60 respondents answered ‘other’ to “How would you describe your sexual orientation?” Queer (n=22, 2.4% of total study respondents) Not sure (n=12, 1.3% of total) Other (n=26, 2.8% of total)

Distribution of High Risk Behaviors: Number of Sex Partners, IDU, and Unprotected Anal Sex Ven diagram

Top Priorities and Concerns Among Participants in GUS in Economic, Relationship, and Health Domains

CONCLUSIONS / IMPLICATIONS For MSM, engaging in high-risk sexual behaviors was not associated with having a regular medical provider Injection drug users were less likely to have a provider Important for providers to understand that MSM who access health care may engage in a wide range of HIV-risk behaviors. Men who were older, more educated, and with higher income were more likely to have a regular medical provider. Respondents with health priorities/concerns were more likely to have a medical provider but not those with economic or relationship priorities/concerns.

OUTLINE Current HIV Climate General Principles HIV Testing and Medical Care Providers Treatment Cascade Emerging Issues

HIV Treatment Centers for Disease Control and Prevention (CDC) estimated 1.2 million people living with HIV infection in the U.S. Early identification of HIV is beneficial for individual health-related outcomes and community prevention. Estimated 51% of new infections due to persons unaware of HIV status. Source: http://www.cdc.gov/vitalsigns/HIVtesting/

The Prevention to Care Continuum HIV Testing Linkage to Care Need for integrated approach to HIV – prevention to treatment 2009 Youth Risk behavior Survey (YRBS) , 34% had sex in the 3 months before the survey and 39% did not use a condom *Adapted from the Hader ‘s Conceptual Framework

Greater Focus on ART Initiation Increased evidence from studies supporting the ‘treatment as prevention’ model Clinical guidelines now recommend starting ART unless specific reason to postpone National HIV/AIDS Strategy for the US, 2010 2nd goal of strategy: Increase access to care and optimize health outcomes

Definition of “In Care” Engaged in Care – broader definitions HRSA Definition ‘Unmet Need’ An individual with HIV or AIDS has an unmet need for care when there is no evidence of any of the following three during a 12-month time frame: (1) viral load (VL) testing, (2) CD4 count (3) provision of anti-retroviral therapy (ART). Clinical measures Medical visits, lab reports ART adherence Accessing services Case management Mental health Substance abuse

Obstacles to Measuring Who is In Care and Out of Care Accurate Information Finding Individuals Not in Care Obtaining complete, reliable and systematic sources of data for labs, medical care visits, and ART use Determining if proxy measures (such as lab results) for medical care are reliable. Movement in and out of State, deaths Difficult to access through traditional means (clinics, AIDS service organizations) Individuals may have distrust of government and other institutions Fear and stigma may be an issue

An Alternative Explanation Why Individuals Out of Care Are So Difficult to Find? Study Context Study Results Study in King County, WA identified 240 persons with HIV that appeared to be not in care Used persons with a new HIV diagnosis in WA from 2004-2006 Not in care defined as no CD4 or viral load lab test for 12 months or longer After contacting and interviewing persons: 12 persons (5%) were truly out of medical care 44 (18%) could not be contacted – status unknown 93 (39%) were in care 86 (36%) had moved 5 (2%) had died Buskin et al. HIV infected individuals presumed to not be receiving HIV medical care, jHASE, 2011.

Length of Time to Enter Medical Care Using HARS, 2006-2010 Study Question Study Design How quickly do newly HIV diagnosed individuals enter medical care and what are the obstacles to entering care? Participants: A resident of Utah when diagnosed with HIV and did not receive a concurrent AIDS diagnosis. Newly reported HIV cases from 2006-2010

Figure 1: Participant Flow Chart for Individuals in the Study 746 Newly Diagnosed HIV Cases in Utah during 2006-2010 Excluded (n =224) Diagnosed initially in other state (n=146) Concurrently diagnosed with AIDS (n=78) 522 Included in Study Did not enter care within study period (n=63) Advantage of survival analysis is individuals without outcome can still contribute information until censored Entered medical care (n=449) Did not enter medical care (n=73) Moved out of State (n=5) Died (n=5)

RESULTS Time from initial diagnosis to entry into medical care 65% enter care within 90 days 21% enter care after 90 days 14% no evidence of entering care Almost half entered care within the first 30 days. Almost half (47.3%) entered care within the first 30 days.

CONCLUSIONS / IMPLICATIONS In this study, the first few months after a diagnosis appears to be the best opportunity to link individuals into care Individuals with no identified risk / no risk reported had a 38% lower adjusted odds of entry into medical care. Individuals with undisclosed risk may benefit from more extensive post-HIV counseling History of MSM/IDU approached significance as a predictor for early entry to medical care Future studies can benefit from more complete and additional collection of information in eHARS History of MSM/IDU approached significance (p=0.09)

OUTLINE Current HIV Climate General Principles HIV Testing and Medical Care Providers Treatment Cascade Emerging Issues

2012 Pilot Project for HIV positive persons out of care CDC’s Medical Monitoring Project http://www.cdc.gov/hiv/topics/treatment/MMP/index.htm Includes 23 projects areas Answers the questions: How many people are receiving care for HIV? How easy is it to access care and use prevention and support services? What needs are not met? How is treatment affecting people living with HIV/AIDS? 2012 Pilot Project for HIV positive persons out of care Five sites for two years Information collected by surveys Concerned with people who never entered care and people who dropped out of care Participants will be re-linked into medical care

From Public Health Silos to Systems

REFERENCES 1. CDC. HIV In the United States Fact Sheet. January 2012; http://www.cdc.gov/hiv/resources/factsheets/us.htm. Accessed February 13, 2012. 2. CDC. HIV among Gay, Bisexual and Other Men who Have Sex with Men (MSM). 2010; http://www.cdc.gov/hiv/topics/msm/index.htm. Accessed November 8, 2011. 3. Zolopa A, Andersen J, Powderly W, et al., Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009,4(5):e5575. 4. Castilla J, Del Romero J, Hernando V, Marincovich B, Garcia S,Rodriguez C, Effectiveness of highly active antiretroviral therapy in reducing heterosexual transmission of HIV. J Acquir Immune Defic Syndr. 2005,40(1):96-101. 5. Branson BM, Handsfield HH, Lampe MA, et al., Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006,55(RR-14):1-17; quiz CE11-14.

Email: mike.lowe@utah.edu Contact Information Michael Lowe, PhD, MSPH Adjunct Professor Email: mike.lowe@utah.edu