Janet C. Cleveland, MS Deputy Director, Prevention Programs Division of HIV/AIDS Prevention South Carolina HIV/STD Conference Columbia, SC October 24, 2012 Engaging Communities: Achieving Maximum Impact to Reduce New HIV Infections in the US National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HAIDS Prevention

Overview  State of the U.S. HIV Epidemic  Strategic Frameworks for HIV Prevention  High Impact Prevention in Theory  High Impact Prevention in Practice  Conclusions

State of the U.S. HIV Epidemic: Where We Stand

The U.S. HIV Epidemic: Where We Stand HIV Prevalence and Incidence Hall JAMA 2008; PreJean PlosOne 2011; MMWR 2011

 Men who have sex with men (MSM) are >40 times more likely to have HIV than other men or women  HIV prevalence is associated with population density, region of residence, poverty, education, employment, and homelessness Purcell National STD Prevention Conference 2010; Denning IAS 2010 Health Inequity The U.S. HIV Epidemic: Where We Stand

Stall, AIDS and Behavior The U.S. HIV Epidemic: Where We Stand Lifetime Risk of HIV Infection among MSM Expected HIV Prevalence Age Black MSM All MSM If current trends continue, half of today’s young black MSM will have HIV by age 35 And, for MSM overall, half will have HIV by age 50

CDC HIV Surveillance Report 2010; MMWR October 2010 The U.S. HIV Epidemic: Where We Stand African American1 in 30 Latina1 in 100 Native Hawaiian/1 in 180 Pacific Islander American Indian/1 in 220 Alaska Native White or Asian1 in 500 Health Inequity HIV Diagnosis Rate, 2010 per 100,000 population Lifetime risk of HIV diagnosis among women per 100,000 population

What The Epidemiology Reveals HIV epidemic concentrated in specific geographic areas, with marked racial, ethnic, social, economic disparities African American and Hispanic/Latino men and women continue to face the most severe rates of HIV infection in the country Increasing incidence among MSM, specifically year old black/African American MSM We MUST focus on aligning and targeting resources toward the epidemic

OVERARCHING STRATEGIC FRAMEWORKS

 Decrease annual new HIV infections by 25%  Increase percentage of people with HIV who know their status to 90%  Increase the proportion of newly diagnosed patients linked to care to 85%  Increase the proportion of HIV-infected MSM, African Americans, and Latinos with an undetectable HIV viral load by 20% Key Prevention-Related NHAS Goals NHAS: Achieving the Prevention Goals

Faster action saves lives and resources later Adapted using methods from Hall, et al. JAIDS 2010 Reducing incidence by 25% In 10 years would save 62,000 infections and save $23 billion In 5 years would prevent 109,000 infections and save $42 billion Reducing incidence by 25% In 10 years would save 62,000 infections and save $23 billion In 5 years would prevent 109,000 infections and save $42 billion 12

 Preexposure prophylaxis (73% reduction)  Antiretroviral therapy (96% reduction)  Vaginal microbicide (39% reduction)  Circumcision (50-60% reduction)  Behavioral interventions  Condom distribution programs and HIV testing Advances in HIV Prevention High-Impact Prevention in Theory

Combination Prevention Multiple disciplines and approaches Community Interventions Biomedical Interventions Structural Interventions HIV Testing & Linkage to Care Individual & Small Group Interventions HIV prevention Adapted from Coates Lancet; 2008

Why we need more Combining interventions is not enough All interventions are not effective and all effective interventions are not equal Limited resources demand difficult decisions Must apply the science of implementation to ensure maximum impact

HIGH IMPACT PREVENTION IN THEORY

High-Impact Prevention  Key components  Effectiveness and cost  Feasibility of full-scale implementation  Coverage of targeted population  Interaction and targeting  Prioritizing  Preventing the most HIV and reducing disparities Available for download at:

High Impact Prevention Key Components Effectiveness and cost How well do interventions work in real-world practice? Feasibility of full-scale implementation Can an effective intervention reach its intended population at a scale that will impact the epidemic? Coverage of targeted population If brought to scale, will an intervention make a substantial impact on the epidemic?

CDC HIV ACTIVITIES AND PROGRAMS HIGH IMPACT PREVENTION IN PRACTICE

High Impact Prevention in Practice  $339 million annually, allocated based on HIV prevalence  Allows flexibility based on local epidemic modeling and needs  Focuses on interventions that will have greatest impact on epidemic—75% of budget devoted to 4 key strategies Aligning Resources with the Epidemic Health Department Funding Proportion of Americans Diagnosed with HIV Who Live in Each State (2008)Proportion of CDC Core HIV Prevention Funding—FY2016 2

Testing in health care and non-health care settings Testing of pregnant women Ensure linkage to care and prevention services HIV Testing HIV Prevention with Positives Condom Distribution Structural and Policy Initiatives Four Required Program Components ART and adherence interventions STD screening and treatment Partner services Behavioral interventions for HIV-positive persons Retention and re-engagement in care Focus on people with HIV and at high risk Create enabling environment for optimal HIV prevention and care through policies, regulations, and practice High Impact Prevention in Practice

Recommended Program Components  Applicants with the resources, capacity, and need may consider implementing the recommended program components.  Up to 25% of the budget may be allocated to support the recommended activities.  Applicant may implement all or a variety of the elements listed under each recommended component.

Recommended Program Components (continued) Evidence-based HIV Prevention Interventions Social Marketing, Media, and Mobilization PrEP and nPEP Provide behavioral risk screening followed by individual and group-level evidence-based interventions for HIV-negative persons at highest risk of acquiring HIV, particularly those in an HIV-serodiscordant relationship. Implement community evidence- based interventions that reduce HIV risk. Support syringe services programs (SSPs), where allowable, and according to HHS and CDC guidelines. Support and promote social marketing campaigns targeted to relevant audiences. Support and promote educational and informational programs for the general population based on local needs, and link these efforts to other funded HIV prevention activities. Support and promote the use of media technology or HIV prevention messaging to targeted populations and communities. Encourage community mobilization to create environments that support HIV prevention by actively involving community members. Support Pre-Exposure Prophylaxis (PrEP) Services to MSM at high risk for HIV. Offer Non-Occupational Post- Exposure Prophylaxis (nPEP) Services to populations at greatest risk.

 Expanded Testing Initiative  In first 3 years, 2.8 million tests with 18,000 people newly diagnosed with HIV  70% African American; 12% Latino  Averted estimated 3,381 HIV infections with return of $2 for every dollar invested  MSM Testing Initiative: focus on venue and event- based testing to diagnose 2,500 people with HIV  >50% diagnoses in African American or Latino men High Impact Prevention Fights Inequities High Impact Prevention in Practice

 Program for young MSM and transgender youth of color  $55 million over five years to 34 community organizations  Anticipate 90,000 tests over 5 years with 3,500 newly diagnosed individuals  Behavioral interventions and support services for all clients High Impact Prevention in Practice High Impact Prevention Fights Inequities

 Public health responsibility to close gaps in HIV care and prevention services  Currently only 25% of all people with HIV are virally suppressed  Individual level, lower viral load reduces morbidity and mortality for people with HIV, and less likely to spread HIV  Population level, viral load leads to fewer new infections Strengthening the Public Health Approach to HIV High Impact Prevention in Practice

NCHHSTP ATLAS An interactive platform for accessing HIV, viral hepatitis, STD & TB data Users can create detailed reports, maps, and other graphics

ACHIEVING MAXIMUM IMPACT THROUGH ENGAGING COMMUNITIES: HIV PLANNING

Jurisdictional HIV Prevention Planning All funded jurisdictions are required to have in place a prevention planning process to include: Jurisdictional HIV Prevention Plan HIV Prevention Planning Group (PPG)

What is HIV Planning? HIV planning is a critical process by which health departments work in partnership with the community and key stakeholders to enhance access to HIV prevention, care, and treatment services for the populations at highest risk for acquiring or transmitting HIV infection.

CDC’s Expectations for HIV Planning  To improve HIV prevention programs by strengthening the: 1) scientific basis 2) community relevance 3) key stakeholder involvement 4) population or risk-based focus of HIV prevention interventions in each jurisdiction 5) communication and coordination of services across the continuum of HIV prevention, care, and treatment, including social determinants of health associated with HIV, STDs, substance abuse, and mental health

Fundamentals of HIV Planning A basic fundamental tenet is: Parity, Inclusion, and Representation (PIR) –Parity: The ability of HPG members to equally participate and carry out tasks or duties in the planning process –Inclusion: Meaningful involvement of members in the process with an active role in making decisions –Representation: The act of serving as an official member reflecting the perspective of a specific community

Other Fundamentals of HIV Planning –HIV planning is a participatory and collaborative process that ensures engagement in an ongoing dialogue with the HD in the planning process –HIV planning must actively encourage and seek key stakeholders and community participation –Nomination for HPG membership should be solicited through an open process –Comprehensive participation is critical to the success of the jurisdictional plan and HIV planning process –HPGs must adopt a High Impact Prevention approach to HIV prevention activities in their communities and use the most current data to guide the planning process

Relevance of HIV Planning HIV planning is a critical component in implementing NHAS and HIP Informs the development of the Jurisdictional HIV Prevention Plan Provides the opportunity to communicate and coordinate funded CDC, HRSA, and SAMHSA activities at the local level

ACHIEVING MAXIMUM IMPACT THROUGH HEALTH COMMUNICATIONS

Act Against AIDS Goal: Support reduction of HIV incidence in the U.S. through effective, evidence-based communication, marketing and education campaigns Target Audiences: The general public Populations most affected by HIV- -gay, bisexual and other men who have sex with men (MSM), black men and women, Hispanics/Latinos Health care providers

Campaigns targeted to healthcare providers Prevention is Care HIV Screening. Standard Care. One Test. Two Lives.

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Conclusions  Growing number of people with HIV and restricted budgets require higher impact strategies  Must act swiftly as window for success may be closing  Further success will require thoughtful prioritization and new and improved programs and interventions  Reducing HIV incidence and ending disease transmission will require community mobilization and prevention partners

Conclusions, cont.  Large disparities require conscious application of health equity approaches  Powerful tools and enhanced understanding are required  Integrate public health prevention, care, and surveillance programs

Acknowledgements Jonathan Mermin Michelle Bonds Nick DeLuca Jackie Rosenthal Amy Stone Amy Lansky Wendy Lyon Irene Hall Stephanie Sansom June Mayfield