Status of the U.S. HIV/AIDS Epidemic: Is it changing, and if not, why not? Harold W. Jaffe, M.D. Department of Public Health University of Oxford

HIV/AIDS in the United States What is the magnitude of the epidemic? What interventions prevent HIV transmission? What needs to be done?

AIDS Cases and Deaths Reported 1981 – 2005, United States Deaths Cases Adults/Adolescents 979, ,529 Children (<13 years) 9,0894,865 Total 988, ,394

Estimated numbers of AIDS cases by year of diagnosis United States,

Males Females Year Estimated Number of Adults and Adolescents Living with HIV/AIDS, by Sex, 33 States, No. of persons (in thousands)

Cases, % Year of diagnosis Proportion of HIV/AIDS Cases among Adults and Adolescents, by Transmission Category 33 States, Male-to-male sexual contact High-risk heterosexual contact* Male-to-male sexual contact and IDU Injection drug use (IDU)

Cases, % Year of diagnosis Black, not Hispanic Hispanic Asian/Pacific Islander White, not Hispanic Proportion of HIV/AIDS Cases among Adults and Adolescents, by Race/Ethnicity, 33 States, American Indian/ Alaska Native

Estimated Number of New HIV Infections Annually, United States R. Brookmeyer. Science 1991; 253:37

Current Status of National HIV Incidence Surveillance TX AZ CA SF LA Cty PR FL GA ALMS LA SC NC VA PA NYS OH IN MI IL MO TNOK CO WA CHI HOU MA CT NJ NYC MD DC Phil

HIV-1 Capture EIA (BED)* Captures both HIV and non-HIV IgG antibodies Proportion of HIV antibodies increases with duration of infection Low proportion generally indicates recent infection *Uses synthetic peptides that represent B,E, and D subtypes

National HIV Behavioral Surveillance (NHBS) Rotating annual cycles of surveillance in MSM, IDU, and heterosexuals in high-prevalence areas Face-to face interviews on risk behaviors, HIV testing, and use of prevention programs Minimum of 500 eligible persons from each participating area

NHBS in MSM Venue-based sample of 10,030 men in 15 U.S. cities, Nov 2003-April % of participants reported unprotected anal sex with male partner in last 12 mo. Approx 11% of HIV-negative men reported unprotected anal sex with partner of unknown infection status at most recent sexual encounter MMWR 2006;55:SS-6

New Test Implementation and Declining Risk of Viral Infections from Transfusion M P Bush, et al. JAMA 2003; 289:959

Estimated numbers of AIDS cases in children <13 years of age, by year of diagnosis, United States, ,

Risk Factors for Transmission after Percutaneous Exposure to HIV- Infected Blood Adjusted odds Risk Factor ratio (95% CI) Deep injury 15 (6.0-41) Blood on device 6.2 (2.2-21) Needle in blood vessel 4.3 (1.7-12) Terminal illness in source 5.6 (2.0-16) PEP with AZT 0.19 ( ) DM Cardo, et al. N Engl J Med 1997;337:1485

Condoms “ (Male) latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV” CDC. Fact Sheet for Public Health Personnel. Male Latex Condoms and Sexually Transmitted Diseases

Incident HPV after first intercourse and condom use by male partner, 82 U.S. female college students Frequency condom use Adjusted hazard P-value ratio (95% CI) <5% % 1.0 ( ) % 0.5 ( ) % 0.3 ( ) RL Winer, et al. N Engl J Med 2006;354:2645

Impact of Male Circumcision on Female-to-Male HIV Transmission 1 B Auvert, et al. PLoS Medicine 2005;2:e298 2 NIAID Press Release, Dec 13, 2006 Study SiteNo. MenEst. Efficacy South Africa % Kenya % Uganda %

Systematic Review of HIV Behavioral Interventions, U.S., “best evidence” interventions identified from 100 unique studies Target populations include MSM, high-risk adults and youth, IDUs, HIV+ persons Significant effects included reduced unprotected sex or STDs from 3-12 mo. after intervention HIV incidence not an endpoint CM Lyles, et al. Am J Public Health 2007;97:133

Behavior Change following HIV Diagnosis, United States Meta-analysis of sexual behavior before and after HIV diagnosis Effect measured by self-reports of unprotected anal or vaginal intercourse, adjusted to include only “at-risk” partners Model of data from 5 studies indicates average risk reduction of 64% (57-71%) G Marks, et al. JAIDS 2005;39:446

What might work to prevent HIV transmission? Vaccines Topical microbicides Cervical barriers (diaphragms and caps) Pre-exposure prophylaxis Treatment to reduce infectivity Prevention of HSV-2 infection

Needle and Syringe Exchange “Moderate evidence indicates that multi component HIV prevention programs that include needle and syringe exchange reduce intermediate HIV risk behavior. However, evidence regarding the effect of needle and syringe exchange on HIV incidence is limited and inconclusive.” Institute of Medicine. Preventing HIV infection among injecting drug users in high risk countries: An assessment of the evidence. (2006)

Cochrane Review of Abstinence- only Programs for HIV Prevention Eight published RCTs; all involve U.S. youth (N=13,191) Programs based in schools (6), home (1) and community (1) Median follow-up of 12 months No significant risk reduction indicated by self- reported behavioral or biological outcomes K Underhill, et al. Cochrane Database of Systematic Reviews (in press)

An Abstinence-only Intervention for Young Adolescents RCT of 4 interventions in 662 African-American adolescents ages Endpoint of self-reported sexual activity over 24 months Significantly less sexual activity reported in abstinence-only (AO) group However, ~30% of virgins in AO group became sexually active during follow-up JB Jemmott, et al. Abstract MOAX0504, Toronto International AIDS Conference, 2006

“AIDS is a war against humanity” Nelson Mandela Barcelona, 2002