The HIV virus

The overwhelming majority of people with HIV live in low- and middle-income countries. Sub- Saharan Africa accounts for two-thirds of all infected people. South and South-East Asia has the second highest number of people living with HIV. HIV/AIDS worldwide by region

El-Sadr WM, Mayer KH, Hodder SL. AIDS in America - Forgotten but not gone. NEJM 362(11):968, 2010.

A Global View of HIV Infections Among Adolescents and Young Persons

UNAIDS Global Report, 2012

UNAIDS Global Report, 2010

Ortblad et al. The burden of HIV. AIDS 27(13):2006, 2013.

Ortblad et al. The burden of HIV. AIDS 27(13):2008, 2013.

Children orphaned by AIDS 0-14 years, (most recent) by country

DETERMINANTS OF TRANSMISSION FROM AN INFECTED PERSON(1) Duration of infection/stage of disease Risk of transmission per sexual act –Viral RNA level –Presence/absence of concurrent STD and other infections –Condom use –Treatment

DETERMINANTS OF TRANSMISSION FROM AN INFECTED PERSON (2) Circumcision status (reservoir of HIV) Partner exchange rate –Mixing pattern –Patterns of sexual behavior (anal, vaginal, etc.) –Injection equipment sharing –Networks, core transmitters

TARGET GROUPS FOR INTERVENTION STRATEGIES Youth years Men who have sex with men Injection drug users Promiscuous heterosexuals Health care workers Biomedical laboratory workers Blood/plasma donors Pregnant women in high-risk populations Persons living with HIV/AIDS Spouses of high-risk persons

BARRIERS TO HIV/AIDS CONTROL (1) Stigma (risk groups, HIV-infected, testing) Status of women Low condom acceptance (esp. for non- commercial sex) Emphasis (& $s ) on treatment, not prevention Dependence on external support Long-term sustainability of external support Low awareness/acceptance of vulnerability (women/youth)

BARRIERS TO HIV/AIDS CONTROL (2) Low acceptance of testing (emphasis on “opt-in” and individual rights) High proportion of uncircumcised men Reluctance to be circumcised Low literacy rates Effectiveness of female-controlled prevention strategies (e.g. microbicides) Vaccine unlikely in the near future High proportion of asymptomatic STIs

Prep and Pep – will it be utilized

Key Elements for Successful Intervention (1) Mobilization of political will and commitment Good surveillance Learn and adapt from past experiences Unified national planning Multisectoral response; e.g., police Rapid implementation Focused intervention; e.g., involve marginalized and high-risk groups

Key Elements for Successful Intervention (2) Assure access to intervention tools; e.g. condoms, testing, drugs Early education before exposure Community involvement Access to treatment Compliance/adherence/sustainability Intensified testing efforts Combining strategies

Key Elements for Successful Intervention (3) Reduce barriers to intervention Address restrictive cultural norms (e.g. refusal to acknowledge sexuality) Stigmatization Promote testing (opt out) Treatment as prevention Adults Pregnant women Development of effective vaccine

Key Elements for Successful Intervention (4) Testing for an effective microbicide –Issues of testing i.e. mandatory condom use –Recognition of risk by participants –Inducing essential level of adherence –Drug resistance for anti-HIV microbicides

Key Elements for Successful Intervention (5) PreP –Efficacy at individual level –Achieving essential adherence levels –Low effectiveness  increased resistance and increased community viral load –Cost – who pays? –Target groups PEP –Speed/interval post-exposure essential –Cost-effective if it prevents HIV –Who pays? –Identifying exposure

THE HIV/AIDS EPIDEMIC IN THE U.S. THROUGH 2011

Black Americans and HIV/AIDS. HIV/AIDS Policy, Kaiser Family Foundation, March 2013.

Slide 2: Rates of Diagnoses of HIV Infection, States and 5 U.S. Dependent Areas In 2010, in the 46 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2007, the estimated rate of diagnoses of HIV infection was 16.3 per 100,000 population. The estimated rates of diagnoses of HIV infection ranged from 0.0 per 100,000 in American Samoa and the Northern Mariana Islands to 42.8 per 100,000 in the U.S. Virgin Islands.

Slide 9: Rates of Adults and Adolescents Living with a Diagnosis of HIV Infection, Year-end States and 5 U.S. Dependent Areas At the end of 2009, in the 46 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2007, the estimated rate of adults and adolescents living with a diagnosis of HIV infection was per 100,000 population. The estimated rates of adults and adolescents living with a diagnosis of HIV infection ranged from 4.4 per 100,000 in American Samoa to per 100,000 in New York.

The HIV/AIDS Epidemic in California

California Department of Health Services, Office of AIDS, HIV/AIDS Case Registry Section, Dec 2013

The HIV/AIDS Epidemic in Los Angeles

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; pg 4

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; pg 5

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; pg 9

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; pg 32

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; pg 33

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; pg 35

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; pg 40

Los Angeles County Dept Public Health, Office of HIV/AIDS, 2013 HIV Annual Surveillance Report, April 2014; Appendix