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

2. 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.

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

4. Changing Epidemic – The First 20 Years

6. AIDS 2012 Conference -- BIG Names

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

8. Field of HIV Research

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

10. 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.

11. 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.

12. 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

13. 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

14. 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)

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

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

17. 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.

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

19. 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:

20. 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

21. 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

22. 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

23. 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

24. 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
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.

25. 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

26. Figure 1: Participant Flow Chart for Individuals in the Study
746 Newly Diagnosed HIV Cases in Utah during
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)

27. 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.

28. 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)

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

30. 2012 Pilot Project for HIV positive persons out of care
CDC’s Medical Monitoring Project
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

31. From Public Health Silos to Systems

32. REFERENCES
1. CDC. HIV In the United States Fact Sheet. January 2012; Accessed February 13, 2012.
2. CDC. HIV among Gay, Bisexual and Other Men who Have Sex with Men (MSM). 2010; 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):
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.

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