Inside This Issue: News on the U.S. HIV epidemic, organ transplantation, HIV transmission, guidelines, and reports and educational resources.
The U.S. HIV Epidemic
President Trump Announces “Plan for America” to End the U.S. HIV Epidemic
In his State of the Union address on February 5, U.S. President Donald Trump announced a new initiative, “Ending the HIV Epidemic: A Plan for America,” which has the goals of reducing new U.S. HIV infections by 75% in the next five years and by 90% in the next ten years, thereby averting more than 250,000 HIV infections during the coming decade. The plan will concentrate on the following major areas of action, according to Alex Azar, secretary of the U.S. Department of Health and Human Services (HHS):
- Increasing investments in geographic hotspots through existing, effective programs, such as the Ryan White HIV/AIDS Program, as well as a new program through community health centers that will provide medicine to protect persons at highest risk from getting HIV.
- Using data to identify where HIV is spreading most rapidly and guide decision-making to address prevention, care, and treatment needs at the local level.
- Providing funds for the creation of a local HIV “HealthForce” in targeted areas to expand HIV prevention and treatment.
The initiative will target resources to areas with the highest burdens of HIV infection. These include 48 U.S. counties, Washington, D.C., and San Juan, Puerto Rico – areas that together account for more than half of all new HIV diagnoses. Also targeted are seven states that have a substantial rural HIV burden – with over 75 cases and 10% or more of their new HIV diagnoses in rural areas: Alabama, Arkansas, Illinois, Mississippi, Missouri, Oklahoma, and South Carolina.
The Plan will rely on four key strategies to end the U.S. HIV epidemic, encapsulated by the action verbs “diagnose, treat, protect, and respond.”
The diagnose strategy aims to diagnose all persons living with HIV as early as possible after they are infected with the virus. The U.S. Centers for Disease Control and Prevention (CDC) estimates that about 165,000 Americans are currently living with HIV but don’t know they are infected. “Early detection is critical and can lead to quicker results in treatment and prevent transmission to others,” notes Azar. “Using the latest diagnostics and advanced automation systems, we will make HIV testing simple, accessible, and routine. And we will diagnose infection early and connect patients immediately to care.”
The treat strategy involves treating HIV infection rapidly and effectively after diagnosis, and then achieving and sustaining viral suppression. HIV transmission studies indicate that about 87% of the new U.S. HIV infections that occur each year are transmitted by people who are not receiving HIV care and treatment. “We will establish and expand programs to follow up with individuals no longer receiving care – and provide the resources needed to re-engage them in HIV effective care and treatment,” according to Azar. Noting that the Ryan White HIV/AIDS Program has achieved a viral suppression rate of nearly 86%, “We aim to leverage the program’s comprehensive system of care and treatment to increase viral suppression around the country to 90%.”
The protect strategy involves using proven approaches for preventing HIV infection among persons at risk. Azar notes that, of the estimated 1 million Americans who are at substantial risk for HIV and who could benefit from pre-exposure prophylaxis (PrEP), fewer than 10% are actually using PrEP. Substantially increasing PrEP use among high-risk groups could prevent almost 50,000 HIV infections by 2020, Azar notes.
The respond strategy involves rapid detection and response to growing HIV clusters, thereby preventing further transmission. “New laboratory methods and epidemiological techniques allow us to see where HIV may be spreading most rapidly, thereby allowing CDC and other partners to quickly develop and implement strategies to stop ongoing transmission,” according to Azar. “We will work with impacted communities to ensure they have the technology, personnel, and prevention resources to follow up on all HIV cases and to intervene to stop chains of transmission, and to get those impacted into appropriate care and treatment.”
For additional information about the Plan, please see a two-page summary fact sheet, a list of the 48 high-HIV-burden counties and other areas, and an editorial in the journal JAMA by Anthony Fauci (director of the National Institute of Allergy and Infectious Diseases), and Robert Redfield (director of CDC).
NHBS Report Provides Latest HIV Data for Gay, Bisexual, and Other Men Who Have Sex with Men
This month, CDC published the latest report from the National HIV Behavioral Surveillance (NHBS) program, HIV Infection Risk, Prevention, and Testing Behaviors Among Men Who Have Sex with Men: 23 U.S. Cities, 2017. The surveillance report, which is the fifth of its kind focusing on gay, bisexual, and other men who have sex with men (MSM), summarizes data gathered from approximately 10,100 MSM surveyed in 23 major U.S. cities during 2017. Selected highlights of the CDC analysis are summarized below. Please note that the behavioral data are based on self-reports.
HIV prevalence by age: 23% overall, and rising with increasing age from 14% (ages 18-24 years); 19% (25-29 years); 24% (30-39 years); 31% (40-49 years); and 32% (50-60 years).
HIV prevalence by race/ethnicity: 39% among Blacks; 30% among American Indian or Alaska Natives; 20% among Native Hawaiian or other Pacific Islanders; 19% among Hispanics or Latinos; 15% among Whites; and 9% among Asians.
HIV testing rates: 77% tested during the 12 months before the survey; 95% had ever been tested. The proportion of MSM participating in the NHBS who reported being tested in the previous 12 months has continued to rise in the past decade from 62% in 2008, to 66% in 2011, 71% in 2014, and 77% in 2017.
Condomless sex: 72% of both HIV-positive and HIV-negative MSM reported having condomless anal sex with male partners. Rates of condomless anal or vaginal sex with female partners were substantially lower among MSM – 6% vaginal and 2% anal for HIV-positive participants, and 8% vaginal and 3% anal for HIV-negative participants.
Drug and alcohol use: 45% of HIV-negative MSM reported binge drinking, compared to 32% of HIV-positive MSM. Use of any injection drugs was reported more often by HIV-positive MSM (5%) than by HIV-negative MSM (2%). The most common noninjection drugs reported by HIV-positive MSM were marijuana, cocaine, and methamphetamine. For HIV-negative MSM, commonly reported noninjection drugs were marijuana, cocaine, and ecstasy. Noninjection use of prescription opioids was reported by 6% of both HIV-positive and HIV-negative MSM.
Sexually transmitted infections (STIs): The percentage of MSM who reported a diagnosis of any bacterial STI (chlamydia, gonorrhea, or syphilis) during the 12 months before the survey interview was 19% overall, and was higher among HIV-positive MSM (26%) than HIV-negative MSM (18%).
Receipt of HIV prevention: 70% of the participating MSM reported receiving free condoms, and 31% reported taking part in an HIV behavioral intervention. Overall, one in four HIV-negative MSM reported taking antiretroviral medicines (PrEP) in the past 12 months to prevent HIV infection. However, there were notable racial/ethnic differences in PrEP use: Whites (31%), Asians (31%), Native Hawaiian or other Pacific Islanders (25%), Hispanics or Latinos (21%), Blacks (19%), and American Indian or Alaska Natives (14%).
Receipt of HIV care and treatment: Among self-reported HIV-positive MSM, 97% reported having ever visited a healthcare provider for HIV, 72% reported doing so within one month after diagnosis, and 90% reported visiting a healthcare provider for HIV care in the six months before the NHBS interview. Current use of antiretroviral therapy was reported by 92% of self-reported HIV-positive MSM.
NIAID Sponsors First Major Study Tracking Outcomes of HIV+-to-HIV+ Liver Transplants
The National Institute of Allergy and Infectious Diseases (NIAID) is sponsoring the first large-scale clinical trial to track the outcomes of liver transplants between people with HIV at clinical centers across the U.S. The HOPE in Action Multicenter Liver Study (HAMLS) will study the safety of HIV+-to-HIV+ liver transplants by evaluating liver recipients for potential transplant-related and HIV-related complications following surgery. This liver transplantation study is similar to an ongoing clinical trial, launched in 2018, evaluating kidney transplantation between people with HIV.
Although organ transplants between donors and recipients with HIV were first successfully completed in South Africa during 2008, such transplants were illegal in the U.S. until the passage of the HIV Organ Policy Equity (HOPE) Act in 2013. The HOPE Act allows U.S. transplant teams with an approved research protocol to transplant organs from donors with HIV to qualified recipients with HIV and end-stage organ failure – a practice that may shorten the time HIV+ persons have to wait before receiving a transplant. It is worth noting that the transplantation of organs from HIV+ donors to uninfected recipients remains illegal in the U.S.
There is a substantial need for donor kidneys and livers among persons living with HIV (PLWH). PLWH have an elevated risk of end-stage liver and kidney diseases because of damage caused by HIV itself and by common coinfections and associated comorbidities, such as hepatitis B virus, hepatitis C virus (HCV), hypertension, and diabetes mellitus. In addition, some of the antiretroviral drugs used to treat HIV infection may cause kidney or liver damage.
The new study will track the clinical outcomes of 80 liver transplants. All transplant recipients in the study will be living with HIV. Forty will receive livers from deceased donors who had HIV, and 40 will receive livers from uninfected deceased donors serving as the control group. About 8% of people waiting for a liver transplant also require a simultaneous kidney transplant; these recipients will be eligible to receive both organs from a single deceased donor. In addition, persons who are infected with HCV can receive organ transplants from donors with HCV. Health care teams and study participants will be made aware of the HIV and HCV status of the organ donor and will be counseled on HCV treatment.
“Liver transplants are the second most common type of organ transplant performed in the U.S, and the number of people waiting for these life-saving procedures – both with and without HIV – increases every year,” notes Johns Hopkins researcher Christine Durand, principal investigator of the HAMLS. “Should liver transplants between people with HIV be shown to be safe and effective through this research, the donor pool will expand – saving lives and reducing the time that both HIV-negative and HIV-positive people spend on an organ transplant waiting list.”
For more information about the HAMLS, please visit ClinicalTrials.gov under study identifier NCT03734393. For more information about the HOPE in Action Multicenter Kidney Study, please visit ClinicalTrials.gov under study identifier NCT03500315.
Using HIV Molecular Sequence Data to Identify HIV Networks in Low-Morbidity Areas
Partner services – public health interviews in which people living with HIV name their sexual or needle-sharing partners (named partners) – is an important strategy for identifying HIV transmission networks to guide and prioritize HIV prevention activities. Analyzing HIV molecular sequence data, generated from provider-ordered drug resistance testing, can also identify networks of potential transmission partners. Although several recent studies have examined the use of molecular sequence data to identify HIV transmission networks in areas of high HIV morbidity, few have analyzed the use of HIV molecular sequence data to identify transmission networks in low-morbidity areas.
In a new study published in the Morbidity and Mortality Weekly Report, researchers from the Wisconsin Department of Health Services and their colleagues analyzed HIV sequence data from Wisconsin, a low-HIV-morbidity state with an adult and adolescent diagnosis rate of just 4.6 HIV diagnoses per 100,000 population in 2016. The researchers were able to identify molecular clusters and describe demographic and transmission risk characteristics among pairs of persons whose HIV sequences were highly genetically similar (that is, molecular linkages).
The researchers determined that most molecular linkages in Wisconsin were among persons within the same racial/ethnic, risk, and age groups – with the highest percentages of same partnerships observed among Blacks; gay, bisexual, and other men who have sex with men; and persons 20 to 29 years old. Among named partner linkages where both persons had an HIV sequence available, about one-third (33.8%) also had a molecular linkage and were deemed plausible transmission partners.
“The combination of public health interview and molecular sequence data is a powerful new tool for understanding HIV transmission networks and identifying population- or individual-level interventions to reduce HIV transmission and improve health outcomes,” the researchers conclude. In particular, this combined approach “might detect HIV transmission networks not elucidated through traditional public health interviews and identify opportunities for prevention in rapidly growing clusters of HIV infections,” even in states with lower HIV morbidity.
CDC Resources Highlight the Uses of HIV Molecular Data
Late last year, the CDC held a webinar – HIV Data in Action: Update on the Use of Molecular Data to Focus Prevention – to discuss how CDC and health departments use HIV data to ensure prevention interventions reach the populations where they are needed most. The webinar participants discussed how traditional public health approaches and new analytic tools, including HIV cluster detection and response, can help identify where HIV transmission is occurring rapidly and improve prevention efforts in these communities. The CDC has posted a video of the webinar on YouTube, as well as a downloadable PowerPoint presentation. These resources provide plain-language descriptions of HIV transmission networks, how molecular data can be used to identify them, and brief case studies showing how several public health jurisdictions have used this data to identify HIV clusters, increase HIV testing, target at-risk communities for prevention messages, and improve linkage to prevention and care services.
Updates to U.S. Guidelines for Managing Opportunistic Infections
HHS recently revised its guidelines for the management of two opportunistic infections: Mycobacterium avium Complex disease (MAC) in adult and adolescent patients living with HIV infection; and Isosporiasis (Cystoisosporiasis) in children and adolescents living with HIV. According to the updated guidelines, primary prophylaxis for MAC is no longer recommended, regardless of CD4 T-cell count, for people living with HIV who are receiving effective antiretroviral treatment and have attained viral suppression. The revised recommendations for MAC also include guidance concerning drug-drug interactions and dosing of the antibiotic rifabutin when combined with some newer antiretroviral drugs. The Isosporiasis (Cystoisosporiasis) section of the opportunistic infection guidelines provides information on HHS's new recommendation rating system, together with appropriate references.
Reports and Educational Resources
Fact Sheets and Issue Briefs from the Kaiser Family Foundation
During the past month, the Kaiser Family Foundation produced many new and updated fact sheets and issue briefs focusing on HIV/AIDS in the U.S. and globally, U.S. health insurance coverage, and global health policy. These include:
Black Americans and HIV/AIDS: The Basics – This updated fact sheet highlights the epidemic’s impact on Black Americans, providing current data and trends over time. Black Americans have been disproportionately affected by HIV/AIDS since the epidemic’s beginning, and that disparity has deepened over time. Blacks account for more new HIV diagnoses, people estimated to be living with HIV, and HIV-related deaths than any other racial/ethnic group in the U.S.
The HIV/AIDS Epidemic in the United States: The Basics – This updated fact sheet provides the latest data on the U.S. HIV epidemic, including key trends over time, impact by region and population, and information on the U.S. government’s response.
The Ryan White HIV/AIDS Program: The Basics – This fact sheet provides an overview of the Ryan White Program, the largest HIV-specific federal grant program in the U.S.
The Global HIV/AIDS Epidemic – This updated fact sheet provides the latest data on the global HIV/AIDS epidemic, including impact by region, treatment and prevention efforts, and an overview of the U.S. and global responses to the epidemic.
The U.S. & The Global Fund to Fight AIDS, Tuberculosis, and Malaria – This fact sheet examines the key role played by the U.S. in the Global Fund, an independent, multilateral financing entity designed to raise significant new resources to combat HIV/AIDS, tuberculosis, and malaria in low- and middle- income countries.
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) – This fact sheet looks at the history, funding, and future outlook of PEPFAR – the U.S. government’s major global initiative to combat HIV/AIDS.
The U.S. Government and Global Health – This fact sheet provides an overview of U.S. government global health policy and engagement.
Health Coverage of Immigrants – This issue brief provides an overview of health coverage for noncitizens and discusses key issues for health coverage and care for immigrant families in 2019.
Changes in Health Coverage by Race and Ethnicity Since Implementation of the ACA, 2013-2017 – This issue brief indicates that, while people of color experienced large gains in coverage under the Affordable Care Act (ACA), coverage gains stalled or began reversing for some groups, including Whites and Blacks, between 2016 and 2017.
Reports and Other Resources from Various Sources
The following is a list of other recent resources focusing on HIV/AIDS:
Questions to Ask When Planning for Awareness Days – This blog item from HIV.gov includes a list of five questions to help organizations plan their awareness-raising activities and showcase their services around HIV awareness days.
Slide Set: HIV Mortality (Through 2016) – This set of 27 slides from CDC examines trends in HIV-related deaths from the 1980s to the 2010s, with breakdowns by race/ethnicity, gender, age, state and geographic regions, as well as annual death rates for six leading causes of death.
Updated January 2019 APHL Suggested Reporting Language for the HIV Laboratory Diagnostic Testing Algorithm – This document from the Association of Public Health Laboratories is intended to clarify complex testing outcomes and guide laboratory reporting of test results to providers and health department surveillance programs.
Behavioral and Clinical Characteristics of Persons with Diagnosed HIV Infection-Medical Monitoring Project, United States 2016 Cycle (June 2016-May 2017) – This 37-page surveillance report examines sociodemographic and clinical characteristics, prevention activities, use of health care services, self-reported HIV medication use and adherence, depression and substance use, sexual behaviors, and met and unmet needs for ancillary services among a representative sample of participants in the Medical Monitoring Project.