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

2. 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.

3. Estimated HIV Transmission Rate (as percentage of PLWH/A) in the US, 1985-20005 10 15 20 25 30
1985
1990
1995
2000
Holtgrave DR. JAIDS. 2004;35(1):89-92.

4. 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):
2. Marks G et al. AIDS. 2006;20(10):
3. Holtgrave, Pinkerton. JAIDS

5. 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):

6. 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

7. 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.

8. Maryland AIDS Administration
November 2005

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

10. 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

11. 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

12. 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

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

14. 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

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

16. 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.

17. 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

18. 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
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

19. 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

20. 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.

21. 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.

22. 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 Sep;9(3):
2. Knowlton A et al. JAIDS. 2006;41(4):

23. 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.

24. 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.

25. 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 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

26. 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

27. 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

28. 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