Department of Health, Behavior & Society Department of Health, Behavior & Society David Holtgrave, PhD, Professor & Chair © 2005, Johns Hopkins University. All rights reserved.

Modeling HIV Prevention Effectiveness: What Happened and What Would Have Happened Without Prevention Services in Place? Note: Best available estimate of annual HIV incidence since early 1990s is 40,000 infections per year.

Estimated HIV Transmission Rate (as percentage of PLWH/A) in the US, 1985-2000 5 10 15 20 25 30 1985 1990 1995 2000 Holtgrave DR. JAIDS. 2004;35(1):89-92.

Refining Transmission Rates by Knowledge of Serostatus1-3 Unaware of HIV seropositivity Transmission rate estimated at 8.8 to 10.8% Aware of HIV seropositivity Transmission rate estimated at 1.7 to 2.4% 1. Holtgrave DR et al. Int J STD AIDS. 2004;15(12):789-92. 2. Marks G et al. AIDS. 2006;20(10):1447-50. 3. Holtgrave, Pinkerton. JAIDS. 2007.

Estimated Annual HIV Incidence, AIDS Deaths, and Expected AIDS Deaths Scenario US, 1978-2002 Holtgrave DR et al. Int J STD AIDS. 2004;15(12):789-92.

Reduce the number of new HIV infections in the US from an estimated 40,000 to 20,000 per year by the year 2005, focusing particularly on eliminating racial and ethnic disparities in new HIV infections. – Overarching National Goal from the CDC, “HIV Prevention Strategic Plan Through 2005,” January 2001

The U.S. Epidemic: Still an AIDS Death Every 33 Minutes New infections each year 40,000 (1 every 13 min.) People living with HIV/AIDS 1,039,000 – 1,185,000 People with HIV/AIDS not in care 42 – 59% People with HIV who don’t know they’re infected 24 – 27% Note: Data are estimates. Sources: CDC, 2005; Glynn, K. et al., CDC, "Estimated HIV prevalence in the United States at the end of 2003", Presentation at the National HIV Prevention Conference, 2005; Fleming, P., et al., “HIV Prevalence in the United States 2000”, 9th Conference on Retroviruses and Opportunistic Infections, 2002.

Maryland AIDS Administration November 2005

Maryland Population by Race/ethnicity Maryland AIDS Administration November 2005 *2000 Census

2004 HIV/AIDS Cases by Race/ethnicity Incident HIV Cases* Incident AIDS Cases* *Cases newly diagnosed during 7/1/03 – 6/30/04; reported through 6/30/05 Maryland AIDS Administration November 2005

HIV Incidence and CDC’s HIV Prevention Budget (in 1983 Dollars), US, 1978-2006 180,000 HIV incidence CDC HIV prevention budget $500,000,000 160,000 $450,000,000 $400,000,000 140,000 $350,000,000 120,000 $300,000,000 100,000 $250,000,000 80,000 $200,000,000 60,000 $150,000,000 40,000 $100,000,000 20,000 $50,000,000 000 $- 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Holtgrave & Kates, Am J Prev Med, 2007

The “Next” National Goal (Just One Possible Proposal) By 2010, reduce new HIV infections in the US to 20,000 per year or less, paying particular attention to racial/ethnic health disparities Between now and 2010, annual progress toward the goal should be achieved in terms of (a) national investment (b) process measures (in terms of policy implementation, barrier reduction and service delivery), and (c) annual outcomes assessment

Potential Impact on HIV Incidence of Three Program Types *Disease elimination program essentially unrelated to knowledge of serostatus Based on Holtgrave, PLoS Medicine, 2007.

Overview of Needed Services General Population of U.S. Aware HIV+; No Risk Beh. Unaware HIV+ HIV- at Continued Risk Care/Tx Aware HIV+; Risk Behavior Holtgrave, McGuire, Milan: AJPH, 2007

Levels of HIV Prevention Interventions Individual Dyad Family Group Community Structural laws and policies; environment; social determinants

Overview of HIV Prevention Interventions Sexual transmission Small groups Counseling & testing Community-level Structural-level STI diagnosis and treatment Perinatal transmission AZT; nevirapine Breast-milk supplementation Parenteral transmission Blood safety Occupational setting precautions IDU programs Behavior change Drug treatment Access to sterile injection equipment Valdiserri RO et al. Nat Med. 2003;9(7):881-6.

Baltimore and HIV Approximately… 640,000 residents 80,000 arrested per year 60,000 drug dependent One in four residents below FPL Adjacent to one of richest counties in the nation One murder for every 2100 residents per year 1,000 HIV infections per year 14,500 prevalent HIV cases About ½ of African-American MSM are HIV+; 2/3 of those are not aware

Life Expectancy: Baltimore Amongst Worst in U.S. -- US Average: 76.9 years (2001) -- Baltimore Average: 68.6 years -- 7th worst among US cities -- worst outside of S.D. -- Nearby Montgomery County -- Tied for best in US -- 81.3 years -- Baltimore life expectancy similar to -- Indonesia, 69.87 -- Belize, 68.30 -- Guatemala, 69.38 -- Belarus, 69.08 -- Sources: Harvard School of Public Health, Baltimore Sun, CIA website, and Murray et al in PLoS Medicine, 9/12/2006

This is near the house where I am at This is near the house where I am at. I love clothes but hate to shop hear- it makes me feel bad or poor. I would love to have tons of money to buy really nice stuff. 11/29/2018 © 2005 HMI

Society has overlooked the abilities of impoverished urban residents “(who) have many talents and abilities that are untapped.” Carl Latkin, JHBSPH SHIELD (Self-Help In Eliminating Life-Threatening Diseases) intervention NIDA-sponsored study involved 250 drug users from Baltimore Persons in the experimental group completed a 10-part training session to become peer health educators Compared to the control group, the peer health educators reported having fewer casual sex partners and using condoms more frequently during casual sex Peer health educators also reported less needle sharing Researchers also interviewed members of the peer health educators' social network. An initial analysis suggests that those network members—the recipients of the outreach—have taken steps to reduce their HIV risk behavior.

Jewelry-Making Program Empowers Participants, Reduces HIV Risk Researchers from the Johns Hopkins Bloomberg School of Public Health have found a new way to address HIV and sexual risk taking among drug-using women involved in prostitution. The Jewelry Education for Women Empowering their Lives (JEWEL) program introduced 55 drug-using women to HIV risk prevention and the making, marketing and selling of beaded jewelry. After participating in the program, the women reduced their number of sex partners, spent less on drugs daily and decreased crack use. The study is published in the January 2006 issue of AIDS Care.

Housing as a Kind of HIV Prevention Intervention Higher rates of HIV-related risk behavior among homeless and unstably housed1 Major study underway (sponsored by HUD and CDC and involving JHBSPH) to determine prospectively the impact of housing on HIV-related risk behaviors in Baltimore, Chicago, and LA JHBSPH co-sponsoring annual meeting on homelessness and HIV research, and co-editing special issues of AIDS & Behavior on this topic Amy Knowlton’s research has shown that housing is related to detectability of viral load2 1. Aidala A et al. AIDS Behav. 2005 Sep;9(3):251-65. 2. Knowlton A et al. JAIDS. 2006;41(4):486-92.

Social Determinants of STIs and AIDS Cases US States, 1999 Pearson correlation coefficients across 48 states with available data, df = 46 Gonorrhea Syphilis Chlamydia AIDS Cases Poverty .204 .232 .358* .099 Social Capital -.671* -.591* -.532* -.498* Income Inequality .203 .133 .395* .469* *P <.01 Holtgrave DR et al. Sex Transm Infect. 2003;79(1):62-4.

Results: Bivariate Linear Correlations Between Social Determinants and Teen Pregnancy Rates, 1999 Pearson correlation coefficients across 48 states with available data, df = 46 Teen Pregnancy Rate Poverty .44* Social Capital -.78* Income Inequality .53* *P <.01 Crosby RA et al. J Adolesc Health. 2006;38(5):556-9.

Understanding the role of neighborhood social dynamics in HIV prevention among disadvantaged youth In 2003, a cross-sectional study was conducted among 343 sexually active, low-income African American youth from East Baltimore ages 15-19; participants were recruited from a local STD clinic and the JHU Teen Clinic Investigators found that adolescents living in neighborhoods with higher levels of social cohesion were 1.82 times as likely to use condoms at last sex than those living in less cohesive neighborhoods (54.7 vs. 40.4 percent; p<.0001), controlling for family dynamics and socio-demographic factors. Further research on individual-environmental linkages is urgently needed to more fully understand the mechanisms for this relationship (e.g. does neighborhood cohesion influence self-concept and in turn sexual behavior?) Kerrigan, Witt, Glass, Chung, and Ellen et al 2006

Stepping Up Behavioral Surveillance to Track and Fight HIV/AIDS Conducted in Baltimore by the Bloomberg School in collaboration with the Maryland AIDS Administration and funded by the Centers for Disease Control with the AIDS Administration, BESURE is a multiyear, 25-city, community-based study designed to look at HIV risk behaviors and their prevalence over time in three marginalized populations: MSM; IDU; and heterosexual men and women impacted by poverty and living in areas with high HIV/AIDS prevalence. Frangiscos Sifakis, principal investigator and JHBSPH faculty assistant scientist

Conclusions HIV prevention programs have brought down HIV incidence in the US but are held hostage to flat funding; that fact must be addressed nationally Promotion of serostatus awareness via counseling and testing might get nation to an annual incidence level in the 25,000 to 30,000 range (down from 40,000), but reducing incidence further than that will have little to do with serostatus awareness

Conclusions (continued) A multi-component, multi-level, evidence-based comprehensive national HIV prevention plan for the US is necessary and urgently needed (as UNGASS has suggested) A plan is needed (as are substantial new resources) for providing high quality HIV care and treatment to persons newly identified as HIV-positive by serostatus awareness efforts Much community-based participatory research addressing these factors is underway with JHBSPH involved as one key partner, and more is needed