United States: HIV Epidemic Vijay Kandula, MD MPH AAHIVS Adjunct Assistant Professor Division of Public Health, Department of Family and Preventive Medicine University of Utah, Salt Lake City 2013

HIV Info Everyone Should Know What are the four fluids that can transmit HIV? What are four fluids that cannot transmit HIV? What is the window period with regards to HIV testing?

Common Acronyms MSM IDU CSW PLWHA HAART

The percentage of diagnoses of HIV infection among adults and adolescents exposed through male-to-male sexual contact increased from 55% in 2007 to 61% in 2010. The percentages of diagnosed HIV infections attributed to injection drug use, male-to-male sexual contact and injection drug use, and heterosexual contact remained relatively stable from 2007-2010.   The remaining diagnoses of HIV infection were those attributed to hemophilia or the receipt of blood or blood products, perinatal exposure, and those in persons without an identified risk factor.

~80% of HIV was among males females. From 2008 through 2011, the number of diagnoses of HIV infection among adult and adolescent females decreased; the number among males remained stable. In 2011, an estimated 50,007 adults and adolescents were diagnosed with HIV infection; of these, 79% of diagnoses were among males and 21% were among females.  

What are the other transmission routes? In 2011, an estimated 62% of all diagnosed infections were attributed to male-to-male sexual contact. An estimated 18% of all diagnosed infections were attributed to heterosexual contact for females and 10% for males. An estimated 5% of all diagnosed infections were attributed to injection drug use for males and 3% for females. Approximately 3% of diagnosed infections were attributed to male-to-male sexual contact and injection drug use. Less than 1% of diagnosed infections were attributed to other transmission categories. Other transmission categories include hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified. What % of the transmission occurred due to heterosexual contact? What are the other transmission routes?

In 2011, among males 78% of infections were attributed to male-to-male sexual contact, 12% to heterosexual contact, 6% to injection drug use, 4% to male-to-male sexual contact and injection drug use, and less than 1% to other transmission categories.    Among females, 86% of diagnosed HIV infections were attributed to heterosexual contact, 14% were attributed to injection drug use, and less than 1% to other transmission categories.   Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting. Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection. Other transmission categories include hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

Peak- due to change in definition of diagnosis During the early 1990’s the numbers AIDS cases among whites, blacks/African Americans and Hispanics/Latinos increased, peaked during 1992-1993, and then decreased since that time. However, decreases were not consistent across races/ethnicities AIDS among blacks/African Americans surpassed whites for the first time in 1994 and has remained higher than all races/ethnicities since that time.   http://www.cdc.gov/hiv/topics/surveillance/resources/slides/race-ethnicity/.

Very young MSM is a very high risk group: The percentage distribution of AIDS diagnoses by transmission category has shifted since the beginning of the epidemic. In 1985, male-to-male sexual contact accounted for an estimated 65% of all AIDS diagnoses; this proportion reached its lowest point in 1999 at 40% of diagnoses. Since then, the percentage of AIDS diagnoses among persons with HIV infection attributed to male-to-male sexual contact has increased and in 2010 this transmission category accounted for 50% of all AIDS diagnoses.   The estimated percentage of AIDS diagnoses among persons with HIV infection attributed to injection drug use increased from 20% to 31% during 1985–1993 and decreased since that time accounting for 14% of diagnoses in 2010. The estimated percentage of AIDS diagnoses among persons with HIV infection attributed to male-to-male sexual contact and injection drug use decreased from 9% in 1985 to 4% in 2010. The estimated percentage of AIDS diagnoses among persons with HIV infection attributed to heterosexual contact increased from 3% in 1985 to 31% in 2010. The remaining AIDS diagnoses were among persons with HIV infection attributed to hemophilia or the receipt of blood or blood products, perinatal exposure, and those in persons without an identified risk factor. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting. Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.

Estimated rates (per 100,000 population) of adults and adolescents living with diagnosed HIV infection at the end of 2010 in the United States and 6 dependent areas are shown in this slide.   Areas with the highest estimated rates of persons living with diagnosed HIV infection at the end of 2010 were the District of Columbia (2,704.3), New York (810.0), the U.S. Virgin Islands (667.1), Maryland (632.9), Florida (592.7), Puerto Rico (584.3), New Jersey (488.2), Louisiana (451.7), and Georgia (428.8). The District of Columbia (i.e., Washington, DC) is a city; please use caution when comparing the rate of persons living with diagnosed HIV infection in DC with the rates in states. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Persons living with a diagnosis of HIV infection are classified as adult or adolescent based on age at year-end 2010.

High Risk Groups for HIV Individuals with multiple sex partners Individual’s partner has multiple sex partners Injecting Drug Users (IDUs) Sex partners of IDUs People who exchange sex for drugs or money (such as commercial sex workers) Sex partners of HIV infected individuals CDC: HIV in the United States, 2010 http://www.cdc.gov/hiv/resources/factsheets/us.htm#ref2

Trends in Infection Younger People (25 and under) Women, especially among African Americans People in Prison MSM and Injection Drug Users, crystal meth Low Socioeconomic Status / Marginalized Populations

Trends in Infection – cont. Youth (often defined as 13-24) In 2004, an estimated 4,883 young people received a diagnosis of HIV infection or AIDS, representing about 13% of the persons given a diagnosis during that year. Early age at sexual initiation. According to CDC’s Youth Risk Behavioral Survey (YRBS), 47% of high school students have had sexual intercourse, and 7.4% of them reported first sexual intercourse before age 13. HIV/AIDS education needs to take place at correspondingly young ages, before young people engage in sexual behaviors that put them at risk for HIV infection.

Trends in Infection Younger People Women, especially among African Americans People in Prison MSM and Injection Drug Users, crystal meth Low Socioeconomic Status / Marginalized Populations

Trends in Infection – cont. African Americans At the end of 2007, blacks accounted for almost half (46%) of people living with a diagnosis of HIV infection Women AIDS is a common killer, second only to cancer and heart disease for women. African American Women In 2006, the rate of new HIV infection for black women was nearly 15 times as high as that of white women and nearly 4 times that of Hispanic/Latina women.

From 2008 through 2011, the largest percentage of diagnoses of HIV infection each year was for blacks/African Americans. In 2011, the percentages of diagnoses were 46% for blacks/African Americans, 28% for whites, 22% for Hispanics/Latinos, 2% each for Asians and persons of multiple races, and less than 1% each for American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders.  

In 2011, among the 39,495 diagnoses of HIV infection among adult and adolescent males 42% were black/African American, 30% were white, and 23% were Hispanic/Latino. Approximately 2% each was Asian and males of multiple races, and less than 1% each was American Indian/Alaska Native and Native Hawaiian/other Pacific Islander.   Among the 10,512 diagnoses among adult and adolescent females in 2011, 63% were black/African American, 17% were Hispanic/Latino, and 17% were white. Approximately 1% each was among Asians and females of multiple races, and less than 1% each was among American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Hispanics/Latinos can be of any race.

This slide shows a comparison of the estimated rates of diagnoses of HIV infection between males and females by race/ethnicity. In 2010, black/African American males were impacted at disproportionate rates, compared to all other races/ethnicities. Black/African American females were also impacted disproportionately in comparison to females of other races/ethnicities.   The following 46 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2007 (and reporting to CDC since at least June 2007): Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Hispanics/Latinos can be of any race.

Trends in Infection – cont. MSM and Injection Drug Users In 2006, MSM accounted for more than half (53%) of all new HIV infections in the United States, and MSM with a history of injection drug use (MSM-IDU) accounted for an additional 4% of new infections. Sex parties with crystal meth “Party and Play” are high risk for HIV transmission

Summary > 1.1 m are living with HIV infection ~ 1 in 5 (20%) are unaware of their infection Gay, bisexual, and other MSM particularly young black/African American MSM, most seriously affected by HIV. By race, blacks/African Americans face the most severe burden of HIV.

Thank You Vijay Kandula, MD MPH AAHIVS Adjunct Assistant Professor Division of Public Health, Department of Family and Preventive Medicine University of Utah, Salt Lake City 2013