Back HIV/AIDS

HIV / AIDS

NHPC 2015: Evidence for PrEP Efficacy Grows, but Implementation Presents Challenges

Pre-exposure prophylaxis (PrEP) was a major topic at the 2015 National HIV Prevention Conference(NHPC) last week in Atlanta. A growing body of evidence continues to confirm that Truvada PrEP is highly effective for preventing HIV if taken regularly, both in clinical trials and in real-world clinical use. Yet uptake has been uneven, and researchers and front-line health workers are learning about barriers to PrEP implementation and scale-up for diverse population groups.

alt

NHPC 2015: U.S. Syringe Funding Ban Impedes HIV and Hepatitis C Prevention

Providing sterile syringes is a proven effective method for preventing HIV and hepatitis C virus (HCV) infections among people who inject drugs, yet the U.S. government continues to prohibit use of federal funds for this purpose, presenters said at the 2015 National HIV Prevention Conference (NHPC) last week in Atlanta. A federal budget bill now under consideration could lift the funding ban on syringe exchange programs. 

alt

South Africa Approves Tenofovir/Emtricitabine for HIV Pre-exposure Prevention

The Medicines Control Council of South Africa has become only the third country to approve tenofovir plus emtricitabine (marketed in the U.S. as Truvada) for HIV pre-exposure prophylaxis (PrEP), and the only high-prevalence middle- or low-income country to do so, according to an announcement last week. The approval will cover a generic coformulation.

alt

Trials Offer Evidence-based Blueprint for HIV Treatment and Prevention

A trio of major clinical trials -- SMART, START, and HPTN 052 -- provide definitive evidence supporting prompt antiretroviral treatment for all people diagnosed with HIV, both to improve their own health and to reduce the risk of transmission to others, according to a recent commentary published in the December 3 edition of the New England Journal of Medicine. Further, results from the IPERGAY study, published in the same issue, add to the growing body of evidence supporting pre-exposure prophylaxis (PrEP) for HIV prevention.

alt

NHPC 2015: New HIV Cases Decline, but Population and Geographic Disparities Persist

HIV diagnoses have declined by nearly 20% overall during the past decade, but progress has been uneven across demographic groups, according to new Centers for Disease Control and Prevention(CDC) data reported at the 2015 National HIV Prevention Conference taking place this week in Atlanta. One encouraging finding was a leveling off of newly diagnosed infections among black gay and bisexual men in recent years, following a steady rise. The CDC also reported disappointing new data on geographical disparities, showing that death rates among people with HIV are 3 times higher in southern states.

alt

"It is the best of times and the worst of times [in HIV], with some success and some major disparities," said Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, who opened the conference on Sunday and gave a Monday plenary address on the CDC's high-impact HIV prevention initiative, which aims to focus resources on the most effective interventions and the most heavily affected groups.

"All interventions are not effective, and all effective interventions are not equal," Mermin added. "Limited resources demand choices. Targeted PrEP [pre-exposure prophylaxis] and syringe distribution are cost-effective and cost-saving...The biggest impact will come from getting [people living with HIV] diagnosed and into care."

Diagnosis Trends by Demographic Group

The CDC released data at the conference from a national analysis of trends in HIV diagnoses over 2 time periods -- 2005-2014 and 2010-2014 -- to provide both a decade-long perspective and a look at more recent changes.

Findings showed that annual HIV diagnoses in the U.S. fell by 19% overall between 2005 and 2014 (from 48,795 to 39,718 per year), which the agency attributed to "dramatic and continuing declines over the decade among several populations including heterosexuals, people who inject drugs, and African Americans."

Newly diagnosed infections fell by 35% among heterosexuals, by 40% among all women (from 12,499 to 7,533), by 42% among black women, and by 63% among injection drug usersbetween 2005 and 2014. During the more recent period, black women saw the steepest drop, of 25%.

The same level of success was not uniformly seen among men who have sex with men -- a group that accounts for nearly two-thirds of all new HIV diagnoses in the U.S. Overall, new diagnoses among gay and bisexual men rose by 6% over the decade (from 25,155 to 26,612), before stabilizing in recent years at a less than 1% increase. This rise among gay men combined with a decline among heterosexual men led to a modest 11% decrease for all men (from 36,296 to 32,185).

However, for gay men trends differed substantially according to race/ethnicity. White gay and bisexual men saw an 18% decline in newly detected infections over the decade (from 9,966 to 8,207) -- similar to that of the population as whole. In contrast, new diagnoses among black and Latino gay and bi men rose by 22% (from 8,235 to 10,080) and by 24% (from 5,492 to 6,829), respectively.

But there has been an encouraging leveling off in new diagnoses among black men during the last 5 years, with a less than 1% increase. Looking specifically at young black gay and bi men age 13-24, this group experienced a steep 87% increase in newly diagnosed infections over the entire decade (from 2,094 to 3,923), but a 2% decline between 2010 and 2014. Unfortunately, the same trend was not apparent for young Latino men, who saw diagnoses rise by 16% in recent years.

HIV testing remained stable or increased during the study period, according to the CDC, indicating that the decreases or stabilizations cannot be attributed to fewer people being tested.

"Although we are encouraged by the recent slowing of the epidemic among black gay and bisexual men -- especially young men -- they continue to face a disproportionately high HIV burden and we must address it," Mermin stated in a CDC press release. "There is hope that the National HIV/AIDS Strategy and other efforts are beginning to pay off, but we can't rest until we see equal gains for all races and risk groups."

"[This data] tells us that our prevention strategies are working, but progress is uneven across populations," said Eugene McCray, director of CDC's Division of HIV/AIDS Prevention, who presented the data at a plenary address on Sunday. "We urgently need to accelerate access to testing, treatment, and new biomedical prevention strategies so that everyone can protect themselves and their partners."

McCray suggested that it is unlikely that the declines and stabilizations are due to any specific single intervention -- such as pre-exposure prophylaxis or PrEP, which is only now coming into widespread use -- but is more likely attributable to a combination of prevention efforts including getting more people living with HIV into care and on treatment, which both improves their own health and reduces transmission to others.

Geographical Disparities

McCray also presented new data on differences across states in death rates among people living with HIV and in the number of people who know their HIV status.

Data from 2012 show that the national mortality rate among people with HIV was 19.2 deaths per 1000 people. But this varied by state, from a low of 7.9 deaths per 1000 in Vermont to a high of 30.8 per 1000 in Louisiana. Of the 10 states that failed to meet the national goal for reducing HIV deaths, 7 were in the southeast.

Looking at rates of HIV diagnosis, 87% of people in the U.S. knew their HIV status in 2012, but again there was a wide range, from a low of 77% in Louisiana to a high of 93% in New York State and Hawaii. Just 5 states reached the national goal of 90% (Colorado, Connecticut, and Delaware, Hawaii, and New York), and again the worst performing states were in the south.

"It is unacceptable that people with HIV living in many southern states are more likely to die than those living in other parts of the country," Mermin said in another CDC press release. "Some states are making great strides toward getting people with HIV diagnosed and into care, but every state must do this if we are to reach our national goals for prevention and care."

"We need to ensure everyone living with HIV has access to high quality health care no matter where they live," McCray stressed.

12/7/15

References

CDC. HIV Diagnoses Decline Almost 20 Percent, But Progress is Uneven. Press release. December 6, 2015.

CDC. Southern States Trail Rest of Nation in HIV Treatment, Testing. Press release. December 6, 2015.

CDC. Trends in U.S. HIV Diagnoses, 2005-2014. CDC Fact Sheet. December 6, 2015.

Drug Resistance Acquired During HIV PrEP Rapidly Disappears After Discontinuation

Drug resistance acquired in rare cases of HIV infection occurring while on pre-exposure prophylaxis (PrEP) rapidly disappears once the medication is discontinued, investigators with the Partners PrEP Study Teamreport in the January 2, 2016, edition of AIDS. Use of ultra-sensitive tests performed 6 months after seroconversion and discontinuation of Truvada for PrEP failed to find any remaining resistant virus.

alt

NHPC 2015: National HIV Prevention Conference Highlights Progress and Disparities

Pre-exposure prophylaxis (PrEP), integration of prevention and treatment services, and initiatives to reach heavily affected but underserved groups are among the highlights of the 2015 National HIV Prevention Conference taking place this week in Atlanta. While the latest U.S. epidemiological data show that HIV infections are on the decline overall, significant disparities have kept some groups from taking full advantage of recent prevention advances.

The conference, organized by the Centers for Disease Control and Prevention (CDC), brings together more than 3000 public health experts, medical providers, front-line prevention workers, and people living with HIV to discuss the latest advances in HIV prevention science and implementation.

alt

In his opening plenary talk on Sunday, Eugene McCray, director of CDC's Division of HIV/AIDS Prevention, presented new data showing that HIV diagnoses have declinedby 19% overall during the past decade, and that even the group with the highest incidence rate -- black gay and bisexual men -- has seen new diagnoses level off in the past few years.

But substantial disparities continue to hamper response to the HIV epidemic, largely related to socioeconomic status, geographical location, and stigma and discrimination.

"It is the best of times and the worst of times," said Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, who opened the conference on Sunday and gave a plenary talk on Monday about the CDC's high-impact HIV prevention initiative.

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, also spoke at the opening session, offering an overview of the science underlying biomedical HIV prevention. Fauci highlighted the SMART and START trials, which demonstrated that beginning antiretroviral therapy soon after HIV diagnosis protects the health of people living with HIV; HPTN 052, which showed that prompt treatment dramatically lowers the risk of HIV transmission; and the growing body of evidence showing that Truvada PrEP works if taken regularly.

"The science has spoken," Fauci concluded. "There can now be no excuse for inaction."

New CDC Campaigns

The CDC used the conference to launch a new national HIV testing campaign -- Doing It -- that features a diverse array of people from different communities describing why testing is important to them.

"Knowledge about HIV status is empowering," McCray said at Monday's launch event. "When people with HIV learn their status, they take steps to protect themselves and their partners."

The CDC also released a beta version of a new online risk reduction tool to help people assess and lower their HIV risk. The interactive tool lets users compare the risks of different sexual activities and see how various prevention methods -- such as condoms, PrEP, or HIV treatment for people living with HIV -- can affect their level of protection.

"Both of these efforts are designed to help people take control of their health, make informed choices, and reduce their risk for getting and transmittin

g HIV," Mermin said. "With more effective prevention options than ever before, it is essential that we provide accurate information. Now people can choose the best strategies for protecting themselves and their partners from HIV."

Addressing Disparities

The many sessions and workshops at the conference focused on the various disparities that sustain the HIV epidemic and interventions to help overcome them.

Speaking at the opening session, Mindy Fullilove from Columbia University Mailman School of Public Health discussed some of the social determinants of health that can influence people's choices about HIV prevention and treatment. Among these, she said, is gentrification and displacement in some of the cities most heavily impacted by HIV. While San Francisco and New York City are often touted for their successes in curbing their local HIV epidemics, they are losing their most vulnerable populations.

A panel discussion on Sunday looked at the perspectives and needs of people living with HIV, including youth, long-term survivors, and transgender people. Bamby Salcedo of the TransLatin@ Coalition drew attention to the more than 20 transgender women who have been killed this year, and called on government officials, community-based organizations, the pharmaceutical industry, and others to make commitments to address the needs of trans women and men.

A group of advocates took the stage to condemn the exclusion of sex workers from the conference and from the federal government's HIV response. The audience expressed their solidarity by holding up signs depicting a red umbrella, the symbol of the international sex workers' rights movement.

A "counter conference" organized by the People’s Mobilization on the National HIV/AIDS Strategy-- a coalition of advocacy groups including the HIVPrevention Justice Alliance, Drug Policy Alliance, SERO Project, Transgender Law Center, and Treatment Action Group -- focused in more depth on groups that are heavily affected by the HIV epidemic but have not fully benefitted from advances in prevention and treatment advances.

Following Mermin's talk on Monday, a panel of representatives from government health departments and community-based organizations discussed high-impact prevention, which aims to focus resources on the most effective interventions and the most heavily affected groups.

Several sessions looked at the HIV epidemic among people who inject drugs, which has received renewed attention following an outbreak of HIV and hepatitis C infections among opiate users in rural Indiana. PrEP was another key topic, with several sessions looking at implementation in specialty clinics and as part of routine clinical care.(Syringe exchange and PrEP presentations at the conference will be covered in more detail in forthcoming reports.)

"We must scale up PrEP, treatment as prevention, and sexually transmitted disease testing and treatment," said Murray Penner of NASTAD. "We will not be successful if we cannot expand access to medications to everyone who needs them…We must reform broken policies, end criminalization of people living with HIV, and end the federal ban on [funding for] syringe exchange."

12/7/15

Sources

National HIV Prevention Conference. Atlanta, December 6-9, 2015.

CDC. New CDC Efforts Offer Individuals Vital Information to Reduce Personal HIV Risk. Press release. December 7, 2015.