Eugene McCray, M.D. Director, Division of HIV/AIDS Prevention HIV Prevention in the U.S. Working Towards Reducing New Infections for the Greatest Impact CDC New Health Official Orientation Atlanta, GA May 14, 2015 Eugene McCray, M.D. Director, Division of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

DIVISION OF HIV/AIDS PREVENTION National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention Revised 04/16/2015

Strategic Frameworks for Prevention OVERVIEW State of HIV in the U.S. Strategic Frameworks for Prevention Best Practices

STATUS OF HIV IN THE U.S. 1.2 M 1 in 7 50k 4 in 10 3 in 10 4 1.2 million people living with HIV 1 in 7 people do not know their status 50k 4 in 10 3 in 10 Approximately 50,000 new infections annually 4 in 10 people living with HIV 3 in 10 people living are in HIV medical care with HIV achieve viral suppression 4

NHAS AND DHAP STRATEGY The goals of The National HIV/AIDS Strategy (NHAS) and the Division of HIV/AIDS Prevention’s (DHAP) Strategic Plan are aligned to ensure the greatest impact: Decrease incidence of HIV Increase access to care and improving health outcomes for people with HIV Reduce HIV-related health disparities Intensify efforts in communities hardest hit by HIV Available for download at: https://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf

HIGH-IMPACT PREVENTION (HIP) Applying the science of implementation to maximize impact Primary goal is to prevent the largest possible number of new HIV infections and reduce disparities Framework for using data to maximize impact of available resources and technologies Directs effort and resources to the right places, populations, and strategies CDC’s HIP strategy is one way. It tells us how we can focus our activities in order to increase outcomes for PLWH and better prevent transmission. In order to maximize reductions in new HIV infections, prevention strategies need to be combined in the smartest and most efficient ways possible for the populations and areas most affected by the epidemic. High impact prevention is about preventing the largest possible number of new HIV infections and reducing disparities. It is a useful framework for relying on data to maximize the impact of available resources and technologies to prevent the largest possible number of new HIV infections It directs programmatic efforts and resources to the right places, populations and strategies to reduce new HIV infections. In 2013, we and other federal agencies have continued to apply HIP to funding of programs, surveillance, and research. Jurisdictional plans for states and cities now incorporate HIP to optimize investments between buckets (e.g., testing vs. individual-level program) and within buckets (e.g., identify best strategy of linkage). DHAP is helping to identify and implement the mix of HIV prevention approaches likely to have the greatest impact in jurisdictions and communities based on the profile of their local epidemic and an assessment of the gaps in current HIV prevention programs. www.cdc.gov/hiv/policies/hip.html

High Impact Funding Activities HIV/AIDS PREVENTION High Impact Funding Activities Health Departments Flagship prevention program (PS 12-1201) Surveillance program MSM testing, retention and care program Care and Prevention in the U.S. (CAPUS) Funding of CBOs Community prevention projects YMSM and Transgender prevention projects & initiatives Funding of CBAs for services improvement to high risk populations Strategic partnership initiatives We are implementing or will begin to implement in 2015 the following prevention programs: Expanded Testing Initiative (ETI): Increasing the number of persons who are aware of their status is a critical strategy for preventing HIV infections. Overall, ETI is aimed at (1) significantly increasing the number of persons tested in jurisdictions with a high rate of HIV among disproportionately affected populations and (2) supporting implementation of the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. CAPUS iinnovative demonstration projects to reduce HIV in the United States by improving HIV testing, care and prevention services in communities of color, by specifically addressing the “real world barriers” -- social, economic, clinical and cultural -- to HIV testing and care in communities severely affected by HIV. PS 12-1201: funding health departments by directing resources to the geographic areas of greatest need and prioritizing the HIV prevention strategies that will have the greatest impact on the U.S. epidemic. Funding of CBOs Prevention Projects in the U.S. Prevention IS Care which provides HIV prevention tools through health departments/CBOs for medical care providers to use on a daily basis with patients who are living with HIV Community-specific Prevention Projects Our community-based HIV prevention programs reflect local prevention priorities and serve persons at high risk for acquiring or transmitting HIV; we promote collaboration and coordination of HIV prevention efforts among CBOs, health departments, and private agencies; and build the capacity of CDC-funded CBOs delivering selected interventions to persons at high risk for acquiring or transmitting HIV YMSM and Transgender Prevention Projects and Initiatives to support the development and implementation of effective community-based HIV Prevention Programs that serve Young Men of Color Who Have Sex with Men (YMSM of color) and Young Transgender (YTG) persons of color and their partners at high risk for acquiring or transmitting HIV; to increase the number of YMSM of color and YTG persons of color who are aware of their HIV status and linked to care, treatment, and prevention services; to build the capacity of CDC-funded CBOs delivering selected structural interventions, behavioral interventions, outreach or Enhanced HIV Testing with Personalized Cognitive Counseling to YMSM of color and/or YTG persons of color and their partners at high risk for acquiring or transmitting HIV; to ensure provision of HIV prevention and care services; and to promote collaboration and coordination of HIV prevention efforts among CBOs, health departments, and private agencies Funding of 21 capacity-building organizations to provide training and ensure on-the-ground prevention programs and their staff have the skills, information, and organizational support they need to best serve individuals living with, and at high risk for, HIV in their communities

High Impact Policy Activities HIV/AIDS PREVENTION High Impact Policy Activities PrEP/nPEP Guidelines New HIV Testing Algorithm Male circumcision (Post public comment revision) Framework for Prevention with HIV Negative At-Risk Individuals (i.e., risk reduction) Compendium of EBIs Prevention with Positives Guidelines PREP/PEP (published May 2014) With our recent release of new clinical guidelines encouraging health care providers to consider prescribing pre-exposure prophylaxis (PrEP) for patients at substantial risk for HIV, we know that PrEP has the potential to alter the course of the United States if targeted to the right populations and used as directed. We are leading a variety of efforts to support PrEP uptake and address these critical issues for delivery in community settings. We are collaborating with the CDC Foundation to launch an implementation pilot program to identify the practical requirements, costs and impact of PrEP delivery in clinical care settings. We continue to provide ongoing support to state and local health departments on the delivery of PrEP in their jurisdictions and are engaged in prevention education efforts to increase awareness of PrEP among clinicians and consumers alike. We are also working to ensure the recommended postexposure prophylaxis (PEP) regimens are understood. HIV Testing Algorithm (published June 2014) We know from our work with partners in the field that as many as half of labs are already using the new testing algorithm approach, but some labs had been awaiting our formal recommendations Now that we have released our recommendations and they are finalized, we are committed to making sure that all health care professionals and laboratories in the United States understand the benefits of the new approach To that end, we will be disseminating information throughout the country about the new recommendations and their benefits, and working closely with a wide range of our public health partners to help end, re rapid uptake of the new testing approach nationally Male Circumcision A hot topic area continues to be surrounding male circumcision as past recommendations provides male circumcision reduces the risk that a man will acquire HIV from an infected female partner, and also lowers the risk of other STDs , penile cancer, and infant urinary tract infection. In female partners, it reduces the risk of cervical cancer, genital ulceration, bacterial vaginosis, trichomoniasis, and HPV. It is important to note that the recommendations are still in development and we have made no determination at this time about the final content. We are employing a deliberative, evidence-based process for developing the circumcision recommendations, which allows for both external and internal CDC experts to provide input. CDC will also publish draft recommendations for public comment before the content will be finalized. (Whatever the content may include, our final circumcision recommendations will be completely voluntary. While CDC has not yet determined if male circumcision should be recommended for any population, ultimately the decision will rest with individuals and parents. CDC's public health imperative is to provide the best possible information on the risks and benefits to help inform those decisions). Framework for Prevention with HIV Negative At-Risk Individuals (i.e., risk reduction) With the advent of new bio-medical interventions/options such as PrEP for at-risk HIV negative individuals and non-biomedical interventions in general being available for the prevention of HIV, we understand the need to clarify or re-clarify our framework for prevention and especially among at-risk individuals and we are working towards this. Compendium of EBIs (next slide)

PRIORITY ACTIVITIES Improving Surveillance Strengthen surveillance systems by collecting better quality and more data Expanding HIP Activities Transition CBOs and CBAs into HIP activities within jurisdictions with high numbers of HIV infection in the U.S. Focus Areas: HIV testing; linkage; and referrals to partner services; support services for HIV-positive persons and high-risk persons with unknown/negative serostatus Reducing New Infections Among those at high risk including gay and bisexual men and transgender persons (i.e., PrEP implementation)

NATIONAL & STATE HIV PREVENTION PROGRESS REPORTS 10/22/2013 NATIONAL & STATE HIV PREVENTION PROGRESS REPORTS Data show significant progress and continued challenges/gaps Achieving goals will depend on accelerated progress Multiple factors will affect results: High-Impact Prevention implementation  Increased access to health care Reduced funding for HIV prevention Growing number of people living with HIV who need services Program Feedback Data Reports The information provided in the Feedback reports will assist POs and grantees in their monitoring efforts and will help a great deal with keeping grantees on track to achieve their establish objectives Available for download at: www.cdc.gov/hiv/policies/npr http://www.cdc.gov/hiv/policies/progressreports/spr.html PRECLEARANCE DRAFT for Internal Review

AREAS WITH LAWS AND REGULATIONS FOR REPORTING ALL CD4 AND VIRAL LOAD VALUES, OCTOBER 2014 VT NH MA RI CT NJ DE MD DC Laboratory reporting (laws and regulations) Not all values All values, specified All values, not specified Puerto Rico Virgin Islands, U.S.

BEST PRACTICES: Addressing priorities & overcoming barriers

BEST PRACTICE: Testing The Expanded Testing Initiative funded 25 jurisdictions to increase the number of persons aware of their infection (2007-2010) 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3381 HIV infections were averted Of newly identified confirmed HIV-positives 74.3% were linked  to HIV medical care; 71.8% and 58.6% were also referred to partner services and other prevention services Incorporated now into health department FOA (category B)

BEST PRACTICE: Prevention Programs for High-Risk Populations Illinois Department of Health Co-locates medical and social services in East St. Louis to promote access to comprehensive health care, HIV/STD testing and treatment, psychosocial, GED completion, and job placement for young lesbian, gay, bisexual, and LGBT persons of color. Georgia Department of Public Health Uses surveillance data to create maps with HIV care continuum outcomes by county, zip code, and census tract to prioritize planning decisions about testing, linkage, and retention efforts.

BEST PRACTICE: PrEP New York State Department of Health Convened a statewide stakeholder committee to plan for PrEP introduction and scale-up of access Worked with the Medicaid office to enable coverage for PrEP Published state-specific guidelines Provided funding for pilot PrEP delivery sites Washington State Department of Health Created a drug assistance plan to provide medication for PrEP to uninsured persons at high risk of acquiring HIV infection

BEST PRACTICE: Linkage to and Engagement in Care Louisiana Department of Health LaPHIE is an electronic exchange of health info between the DOH and 8 medical centers Exchange surveillance data to alert clinicians that a patient is out of care or unaware of infection .

BEST PRACTICES: Prevention for People Living with HIV and their Partners Florida State Department of Health Conducts Couples HIV Testing and Counseling (CHTC) trainings in collaboration with state and local Health Departments Offering couples a set of evidence-based interventions once their status is known can reduce HIV incidence within couples, and if implemented with sufficient scale and coverage can potentially reduce population-level HIV incidence as well.

BEST PRACTICES Raising Awareness South Carolina Aggressively engages in social marketing campaigns to raise awareness about HIV A partner in the Act Against AIDS Campaign along with 19 of the nation’s African American and Latino organizations and the Start Talking. Stop HIV campaign www.cdc.gov/actagainstaids.gov

BEST PRACTICES Policy Research HIV Criminalization CDC Legal Assessment Project provides information that policy makers use in drafting/revising criminalization laws Current HIV exposure laws Evidence about the risks of transmission “Given that HIV-specific criminal laws may have wide-ranging social implications, states are encouraged to utilize the findings of this paper as a basis to re-examine those laws, assess the laws’ alignment with current evidence regarding HIV transmission risk, and consider whether current laws are the best vehicle to achieve their intended purposes.” Source: Lehman JS, Carr, MH, Nichol AJ, et al. Prevalence and public health implications of state laws that criminalize potential HIV exposure in the United States. AIDS Behav 2014.

CONCLUSION Continued and intensified efforts needed to improve outcomes along the HIV care continuum Success needed at each step of the continuum to increase viral suppression among persons living with HIV Diagnosis Linkage to and engagement in medical care ART prescription Sustained effort from all jurisdictions needed to implement effective strategies to improve the health of people living with HIV and reduce new infections In conclusion, continued and intensified efforts are needed to improve outcomes along the HIV care continuum. Success is needed at each step of each continuum to increase viral suppression among persons living with HIV, including diagnosis, linkage to and engagement in medical care, and ART prescription. Additional, sustained effort from all communities is needed to implement these known, effective strategies to improve the health of people living with HIV and reduce new infections in the United States.  

“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.” —Vision of the National HIV/AIDS Strategy

DHAP Publications and Resources Available by visiting the DHAP website: www.cdc.gov/hiv/dhap/about.html Division of HIV Prevention Centers for Disease Control and Prevention Corporate Square, Atlanta GA MS D-21 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention