1. HIV Infection and Adolescents Lawrence B
HIV Infection and Adolescents Lawrence B. Friedman, MD Director, Adolescent Medicine

2. Objectives
Review HIV/AIDS statistics and demographics for US, FL, and world
Explain basic HIV science facts
Emphasize affects on children, youth, and young adults
Highlight HIV care and treatment factors
Inform about legal issues and testing provisions
Suggest potential HIV prevention strategies

3. Human Immunodeficiency Virus
Discovered by US and French researchers simultaneously in 1983
Retrovirus
Two types (1 & 2)
Most infections HIV-1, with 5 subtypes (B most common in North America)
No cure!

4. HIV and AIDS in Florida
Second in nation for adult/adolescent cases following NY (and recently overtook CA)
Second in nation for pediatric cases <13 following NY
Increased number of new cases in seniors and youth!

5. Rates of Diagnoses of HIV Infection Among Adolescents Aged 13–19 Years, 2013—United States and 6 Dependent Areas N = 1,931 Total Rate = 6.5
In 2013, there were an estimated 1,931 adolescents aged 13 to 19 years diagnosed with HIV infection in the United States and 6 dependent areas. The estimated rate of diagnoses of HIV infection in adolescents was 6.5 per 100,000 population. The rates of diagnoses of HIV infection among adolescents aged 13 to 19 years in 2013 were highest in Louisiana (15.4 per 100,000), Maryland (17.6 per 100,000), and the District of Columbia (43.1 per 100,000).
The District of Columbia (i.e., Washington, DC) is a city; please use caution when comparing the HIV diagnosis rate in DC with the rates in states.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

6. Rates of Diagnoses of HIV Infection Among Young Adults Aged 20–24 Years, 2013—United States and 6 Dependent Areas N = 8,144 Total Rate = 35.3
In 2013, there were an estimated 8,144 young adults aged 20 to 24 years diagnosed with HIV infection in the United States and 6 dependent areas. The estimated rate of diagnoses of HIV infection in young adults was 35.3 per 100,000 population. With the exception of the U.S Virgin Islands (69.9 per 100,000), New Jersey ( 51.0 per 100,000), Illinois (48.7 per 100,000), Nevada (48.3 per 100,000), and New York (42.1 per 100,000), the rates of diagnoses of HIV infection among young adults 20 to 24 years of age in 2013 were highest in the South; specifically, the District of Columbia (151.5 per 100,000), Georgia (86.9 per 100,000), Maryland (79.1 per 100,000), Louisiana (74.2 per 100,000), Mississippi (59.7 per 100,000), Florida (54.1 per 100,000), Texas (45.7 per 100,000), South Carolina (43.6 per 100,000), and North Carolina (40.0 per 100,000).   
The District of Columbia (i.e., Washington, DC) is a city; please use caution when comparing the HIV diagnosis rate in DC with the rates in states.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

7. 1981
First U.S. AIDS cases reported (as Kaposi’s Sarcoma and Pneumocystis Carinii Pneumonia) in New York and California.
First case of AIDS reported in Florida.
Florida AIDS case surveillance began through the Florida Department of Health and Rehabilitative Services, Disease Control Program.
TOTAL AIDS Cases
United States: 152 cases
Florida: 8 cases

8. 1983
An AIDS surveillance program was established within the State Health Office in Florida.
The Centers for Disease Control declared AIDS a reportable disease.
Florida Administrative Code 10D-3 was amended to require physicians to report diagnosed cases of AIDS to the State Health Office.
TOTAL AIDS Cases
U.S.: 4,156 cases
Florida: 236 cases

9. 1984
HTLV-III, later called HIV, was first identified as the virus that causes AIDS.
Active surveillance for AIDS cases began in Florida, with staff assigned primarily in South Florida.
TOTAL AIDS Cases
U.S.: 9,920 cases
Florida: 545 cases

10. 1987
Florida became the first state to establish voluntary, confidential HIV counseling and testing services to all county public health units.
Specific funding obtained to expand HIV prevention education to minorities and community-based groups.
AZT patient care program initiated.
Up to 3,000 calls a month to the AIDS Hotline.
AZT (Retrovir) approved.
TOTAL AIDS Cases
U.S.: 59,572 cases
Florida: 3,748 cases

11. 1989 The “Florida Responds to AIDS” campaign began.
Project AIDS Care (also known as the Medicaid Waiver Program) was established.
FDA authorizes AZT for children.
TOTAL AIDS Cases
U.S.: 115,786 cases
Florida: 9,766 cases

12. 1990
The Ryan White Comprehensive AIDS Emergency (CARE) Act was established.
Evaluation of HIV transmission from health care providers to patients conducted after a report to the Centers for Disease Control and Prevention of a Florida patient contracting HIV from a dentist during the course of treatment.
TOTAL AIDS Cases
U.S.: 161,073 cases
Florida: 13,487 cases

13. 1994 Florida awarded $350,000 by CDC to initiate Community Planning.
The Florida HIV/AIDS Community Planning Group developed the first HIV Prevention Plan for Florida.
Giving AZT to HIV-infected pregnant women would reduce perinatal transmission by two-thirds.
Florida AIDS Health Fraud Task Force established.
FDA approves d4T (ZeritÒ) and OraSureTM saliva HIV test.
TOTAL AIDS Cases
U.S.: 441,528 cases
Florida: 42,166 cases

14. Florida HIV Cases: 2,157 cases
1997
HIV infection reporting began in Florida on July 1st.
The number of persons in the United States living with HIV/AIDS is estimated at 650, ,000 (CDC). The Bureau of HIV/AIDS estimates that 90,000 Floridians are living with HIV/AIDS.
Nelfinavir (Viracept); Delaviridine (Rescriptor); Saquinavir (Fortovase); and Zidovudine, 300 mg and lamuvidine, 150 mg (Combivir) introduced as a new protease inhibitor drugs.
The Bureau of HIV/AIDS held the first Black Leadership Conference on HIV/AIDS.
TOTAL
U.S.: 619,982 cases
Florida: 62,123 cases
Florida HIV Cases: 2,157 cases

15. Florida HIV Cases: 8,946 cases
1998
AIDS Omnibus Act revised, streamlining HIV testing in the private sector.
The legislation streamlined HIV testing requirements for the private sector to encourage the offering of HIV testing.
Preliminary planning of the Florida HIV/AIDS Minority Network initiated.
The Targeted Outreach for Pregnant Women Act (TOPWA) was created by the Legislature (s , F.S.) to address the high incidence of perinatally-transmitted HIV and AIDS in Florida.
TOTAL
U.S.: 688,200 cases
Florida: 67,156 cases
Florida HIV Cases: 8,946 cases

16. Florida HIV Cases: 47,373 cases
2004
Implementation of rapid HIV testing for pregnant women initiated in hospital labor and delivery units statewide.
Rapid HIV testing expanded to 24 sites.
First Bureau sponsored statewide training for HIV/AIDS Case Managers- 8 training sites with over 500 participants.
Behavioral surveillance began.
Specimen collection for Incidence Surveillance began October 1, 2004.
TOTAL
U.S.: 902,223 cases (2003 data)
Florida: 96,792 cases
Florida HIV Cases: 47,373 cases

17. 2010 U.S. Census
Estimated 63 million adolescents/young adults ages 10 – 24 years
39% non-White
17.5% Hispanic or Latino origin
15% Black
4% Asian/Pacific Islander
1% Native American
2% Other

18. LEADING CAUSES OF DEATH FOR AGES 15 - 24
Accidents
Homicides
Suicides
Malignant Neoplasms
Cardiovascular Diseases
HIV Spectrum of Diseases

20. Adolescents are: Not children Not adults
Childlike in thought and behavior still
Adult physically perhaps
Changing with ongoing brain development and cognitive maturation

21. MILESTONES OF ADOLESCENT DEVELOPMENT
Body image concerns/puberty: early adolescence mostly, cognitive changes begin
Independence/emancipation: ongoing throughout, risk- taking during middle adolescence
Identity formation (including sexual identity): ongoing
Future orientation/delineation of functional role: late adolescence mostly, mortality issues, abstract thoughts
PROCESSES ARE UNIVERSAL AND CONSISTENT

22. Diagnoses of HIV Infection Among Persons Aged 13 Years and Older, by Sex and Age Group, 2013—United States and 6 Dependent Areas
In 2013, the distribution of diagnoses of HIV infection by sex varied with age group at diagnosis in the United States and 6 dependent areas. In 2013, females accounted for an estimated 20% of adolescents aged 13 to 19 years diagnosed with HIV infection, compared with 11% of young adults aged 20 to 24 years and 22% of adults aged 25 years and older.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Age group assigned based on age at diagnosis.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.

23. Diagnoses of HIV Infection and Population Among Adolescents Aged 13–19 Years, by Race/Ethnicity 2013—United States
Black/African American adolescents aged 13 to 19 years have been disproportionately affected by HIV. In 2013, in the United States, 14% of adolescents were black/African American, yet an estimated 67% of diagnoses of HIV infection in 13 to 19 year olds were in black/African American adolescents.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
Hispanics/Latinos can be of any race.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.

24. Diagnoses of HIV Infection and Population Among Young Adults Aged 20–24 Years, by Race/Ethnicity 2013—United States
Black/African American young adults aged 20 to 24 years have been disproportionately affected by HIV. In 2013, in the United States, 15% of young adults were black/African American, yet an estimated 57% of diagnoses of HIV infection in 20 to 24 year olds were in blacks/African Americans.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
Hispanics/Latinos can be of any race.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.

25. Adolescents and Young Adults Aged 13–24 Years Living with a Diagnosis of HIV Infection, by Sex and Race/Ethnicity, Year–end 2012—United States and 6 Dependent Areas
At the end of 2012, an estimated 40,634 adolescents and young adults 13 to 24 years of age were living with a diagnosis of HIV infection in the United States and 6 dependent areas.
Of the 30,222 adolescent and young adult males living with a diagnosis of HIV infection, 60% were black/African American, 20% were Hispanic/Latino, and 15% were white. Four percent were males of multiple races, 1% were Asian. Less than 1% each were American Indian/Alaska Native and Native Hawaiian/other Pacific Islander.
Among adolescent and young adult females living with a diagnosis of HIV infection, 64% were black/African American, 18% were Hispanic/Latino, and 13% were white. Four percent of females living with a diagnosis of HIV infection were females of multiple races, 1% were Asian. Less than 1% each were American Indian/Alaska Native and Native Hawaiian/other Pacific Islander.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
The Asian category includes Asian/Pacific Islander legacy cases (cases that were diagnosed and reported under the pre-1997 Office of Management and Budget race/ethnicity classification system).
Hispanics/Latinos can be of any race.
Persons living with diagnosed HIV infection are classified as adolescent and young adult based on age at year-end 2012.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Includes Asian/Pacific Islander legacy cases.
b Hispanics/Latinos can be of any race.

26. Adolescents and Young Adults Aged 13–24 Years Living with a Diagnosis of HIV Infection, by Sex and Transmission Category, Year-end 2012— United States and 6 Dependent Areas
This slide presents the distribution of adolescents and young adults aged 13 to 24 years living with a diagnosis of HIV infection at the end of 2012 by sex and transmission category, in the United States and 6 dependent areas.
Among adolescent and young adult males living with a diagnosis of HIV infection, 79% of infections were attributed to male-to-male sexual contact. An estimated 3% were attributed to heterosexual contact, 3% attributed to male-to-male sexual contact and injection drug use, and 1% to injection drug use. Twelve percent of males aged had infection attributed to perinatal exposure, and 1% of males aged had infection attributed to other transmission categories.
Among adolescent and young adult females living with a diagnosis of HIV infection at the end of 2012, 53% of infections were attributed to heterosexual contact and 6% to injection drug use. An estimated 37% of females aged were living with diagnosed HIV infection attributed to perinatal exposure, and 5% of females aged had infection attributed to other transmission categories.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.
Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.
Persons living with diagnosed HIV infection are classified as adolescent and young adult based on age at year-end 2012.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion,, and risk factor not reported or not identified.

27. Diagnoses of HIV Infection Among Adolescent and Young Adult Males, by Age Group and Transmission Category 2013—United States and 6 Dependent Areas
This slide shows the estimated numbers and percentages of diagnoses of HIV infection among adolescent males aged 13 to 19 years and young adult males aged 20 to 24 years in 2013 in the United States and 6 dependent areas. In 2013, in both age groups, the majority of diagnosed HIV infections were attributed to male-to-male sexual contact: 93% of diagnoses in males aged 13 to 19 years, and 92% of diagnoses in males aged 20 to 24 years.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.
Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

28. Diagnoses of HIV Infection Among Adolescent and Young Adult Females, by Age Group and Transmission Category 2013—United States and 6 Dependent Areas
This slide shows the estimated numbers and percentages of diagnoses of HIV infection among adolescent females aged 13 to 19 years and young adult females aged 20 to 24 years in 2013 in the United States and 6 dependent areas. In 2013, in both age groups, the majority of diagnosed HIV infections were attributed to heterosexual contact: 84% in females aged 13 to 19 years, and 88% in females aged 20 to 24 years.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.
Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes blood transfusion, perinatal exposure, and risk factor not reported or not identified.

29. Diagnoses of HIV Infection Among Adolescents and Young Adults Aged Years, by Transmission Category, 2009–2013 United States and 6 Dependent Areas
This slide presents the distribution of diagnoses of HIV infection by transmission category for adolescents and young adults 13 to 24 years of age diagnosed from 2009 through 2013 in the United States and 6 dependent areas.
Among adolescents and young adults, the estimated percentage of diagnosed HIV infections attributed to male-to-male sexual contact increased from 72% in 2009 to 80% in The percentage of diagnosed HIV infections attributed to heterosexual contact decreased from 20% to 14% during this time. The percentage of diagnosed HIV infections attributed to injection drug use also decreased slightly, from 4% to 3%. The percentage of diagnosed HIV infections attributed to male-to-male sexual contact and injection drug use also decreased slightly, from 3% to 2%.
The remaining diagnoses of HIV infection were infections attributed to hemophilia or the receipt of blood or blood products, perinatal exposure, and those in persons without an identified risk factor.
Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing transmission category, but not for incomplete reporting.
Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

30. Adult HIV Infection Cases, by Sex and Age Group at Diagnosis,
Reported in 2013, Partnership 11a
Adult HIV Infection Cases
by Sex and Age Group at Diagnosis
Reported in 2013, Partnership 11a
Note: HIV Infection Cases tend to reflect more recent transmission than AIDS cases, and thus present a more current picture of the epidemic. With regard to the age group with the highest percent of HIV Infection Cases, recent estimates show that among males, 30% of HIV Infection Cases occur among those aged 40-49, whereas among females 26% of HIV Infection Cases occur among those aged 50 and older.
Males (N=1,115)
Age
% of Cases
Females (N=317)
% of Cases
Note: HIV infection cases tend to reflect more recent transmission than AIDS cases, and thus present a more current picture of the epidemic. With regard to the age group with the highest percent of HIV infection cases, recent estimates show that among males, 29% of HIV infection cases occur among those aged 20-29, whereas among females 28% of HIV infection cases occur among those aged 50 and older.

31. Case Rates* of Adults Living with HIV Disease,
by Sex and Race/Ethnicity, Reported through 2013, Partnership 11a
RATE RATIOS:
MALES
Blacks:Whites, 2.3:1
Hispanics:Whites, 0.8:1
FEMALES
Black:Whites, 12.6:1
Hispanics:Whites, 1:1
Case Rates* of Adults Living with HIV Disease,
by Sex and Race/Ethnicity, Reported through 2013, Partnership 11a
Note: Among black males living with HIV disease reported through 2013, the case rate is 2 times higher than the rate among white males. Among black females living with HIV disease, the case rate is nearly 13 times higher than the rate among white females. The Hispanic male rate is lower than the rate among their white counterpart, whereas the Hispanic female rate is equivalent to the rate among their white counterpart. Data excludes Department of Corrections cases.
*Source: Population estimates are provided by Florida CHARTS.
**Other includes Asian/Pacific Islanders , Native Alaskans/American Indians and Multi-racial individuals.
Race/Ethnicity Male Female
White
Black
Hispanic
Other**
Note: Among black males living with HIV disease reported through 2013, the case rate is 2 times higher than the rate among white males. Among black females living with HIV disease, the case rate is nearly 13 times higher than the rate among white females. The Hispanic male rate is lower than the rate among their white counterpart, whereas the Hispanic female rate is equivalent to the rate among their white counterpart. Data excludes Department of Corrections cases.
*Source: Population estimates are provided by Florida CHARTS.
**Other includes Asian/Pacific Islanders , Native Alaskans/American Indians and Multi-racial individuals.

32. Connect to Protect

33. CASE
16 y/o Caribbean Female diagnosed with pregnancy at JMH Adolescent Clinic, and referred for Obstetrics care. As part of prenatal screening exam and ongoing care, she was offered HIV testing. HIV test was POSITIVE. History revealed no sexual abuse and only 2 lifetime sexual partners (22 y/o Haitian male and 21 y/o Af-Am male).

34. CASE
15-1/2 y/o BM admitted to substance abuse treatment facility by court order for dual diagnosis. On entry, as routine, RPR syphilis test was done. It showed 1:32 reactivity, so he was treated with PCN and offered HIV testing. History revealed by him indicated that he had two sexual encounters, both with female peers (?). HIV test was POSITIVE. Parents are both HIV negative, and he denied ever using injectable drugs.

35. Primary modes of transmission for HIV
Blood
Sexual fluids
Mother-to-child

36. Acute Retroviral Syndrome:
Onset usually 2-4 wk after exposure
May resemble infectious mono or flu
High levels of HIV present in body
Spontaneous recovery in 1-3 weeks
Persistent or severe symptoms may not appear for 10 years or more

37. Natural Course of HIV Infection and Common Complications
1000 VL
900
CD4+ T cells
Relative level of
Plasma HIV-RNA
800
700 TB
CD4+ cell Count
600
500
HZV
Asymptomatic
400
Acute HIV
infection
syndrome
OHL
300
Treatment of HIV infection during this acute HIV is likely to allow the immune system a chance to develop the immune response which allows better control of the virus and decreased rate of progression as seen in animal models.
200
PPE OC
PCP
100 TB CM
CMV, MAC
Months
Years After HIV Infection

38. Defining Exposure: Infectious Body Fluids
Definitely infectious:
blood
semen
vaginal secretions
any visibly-bloody body fluid

39. Defining Exposure: Infectious Body Fluids
Potentially infectious:
cerebrospinal fluid
synovial fluid
pleural fluid
peritoneal fluid
pericardial fluid
amniotic fluid
pus

40. Defining Exposure: Infectious Body Fluids
Not infectious, unless visibly bloody:
feces
urine
nasal secretions and sputum
saliva
sweat
tears
vomitus
What to say here about Hepatitis?

41. Sexual Transmission
Anal
Vaginal
Oral
Most common mode of transmission

42. Risk of Transmission
Probability of infection from single act of intercourse is < 1.0%, but…
Infection can occur from a single sexual contact.
Transmission may be facilitated by other STDs.
STDs increase HIV infectivity and susceptibility.

43. HIV Transmission Any type of unprotected sexual contact
Blood - to - blood contact
Infected female to unborn or newborn child
3 conditions must be met:
HIV must be present in body fluid
Occur in sufficient quantity, and
Have a portal of entry into bloodstream

44. Transmission by Contact with Infected Blood
Shared needles
Blood and blood product transfusion
Organ transplants
Needle-stick injury
? Tattoos/pierces
Risk of transfusion transmission is 1 in 2-3 million

45. Substance Abuse and HIV
Direct transmission from IDU
Sexual transmission while under the influence, 20 poor decision making and disinhibition
Neonatal transmission, 20/mother or mother’s sexual partner being drug user
Immunosuppression
Inability to utilize services

46. Current Approaches to Treatment of HIV
Halt the replication of HIV.
Prevent opportunistic infections.
Treat infections as they occur.
Maintain physical and mental well being.
KISS: Keep It Simple and Safe.
Usual adult PHS/IAS treatment guidelines.
Secondary prevention (including PEP & PrEP)!

47. Combination Therapy Also known as ART Known to:
Slow disease progression
Improve survival
Provide greater virologic and immunologic sustained response
Delay viral mutations/resistance

48. Health Care Maintenance
Open and non-judgmental approach
Confidentiality, gender neutral questioning
Clearly defined goals of therapy
Interdisciplinary team
Support services
School performance
Hopes/aspirations-school, work, life, children
Immunizations
Growth and development
considering virus, toxicity, quality of life, chronicity of illness
birth control

49. Psychosocial Issues of Care
Substance abuse
Educational needs
Mental health care
Housing
Transportation
Financial assistance
Legal/Juvenile justice involvement

50. Perinatal Transmission
Womb
Delivery
Breast-feeding

51. Perinatally Acquired HIV Infected Cases,
State Trends
Perinatally Acquired HIV Infected Cases,
Born in Florida, by Year of Birth, , N=1,220
Perinatally Acquired HIV Infected Cases,
Born in Florida, by Year of Birth, , N=1,220
Note: These data represent a 95% decline in HIV-perinatally infected births from 1993 (N=109) to 2014 (N=6). These data include ALL perinatally acquired HIV Infection cases BORN in Florida.
2014 data are provisional. Two of the babies born in 2014 have developed AIDS. Data as of 06/30/2015.
Yr. # Births
79 2
80 4
81 9
82 7
83 7
84 12
85 23
86 23
87 32
88 49
89 49
90 100
91 95
92 106
93 109
94 99
95 72
96 51
97 65
98 48
99 33
00 29
01 38
02 21
03 20
04 13
05 15
06 19
07 17
08 11
09 9
10 6
11 3
12 8
14 6
Of the 1,220 perinatally infected babies born in Florida from 1979 through 2014, two were born as early as The birth of HIV-infected babies continued to rise through In April 1994, the U.S. Public Health Service released guidelines for zidovudine (ZDV) also known as azidothymidine (AZT), used to reduce perinatal HIV transmission, and in 1995 recommendations for HIV counseling and voluntary testing for pregnant women were published. Florida law, beginning in October 1996 required the offering of HIV testing to pregnant women. As a result of this increase in testing for HIV infection, more HIV positive women could be offered ZDV during their pregnancy. Enhanced perinatal surveillance systems have documented increased use of ZDV among exposed infants and HIV-infected mothers at the prenatal, intrapartum, delivery and neonatal stages.
Prevention of perinatal HIV remains a very high priority in Florida. The use of other medical therapies, including protease inhibitors, has supplemented the use of ZDV for both infected mothers and their babies. The use of these medical therapies has been accompanied by a decrease in the number of perinatally HIV-infected infants and is responsible for the dramatic decline in perinatally acquired HIV/AIDS since Furthermore, numerous initiatives have contributed to the reduction in these cases. Major initiatives include: seven Targeted Outreach to Pregnant Women Act (TOPWA) programs, three perinatal nurses located in the most heavily impacted counties, social marketing, and provider education. These initiatives have helped to further educate local providers in the importance of testing pregnant women for HIV and then offering effective treatment during the pregnancy and at delivery to further decrease the chances of vertical transmission. The use of these medical therapies has been followed by a decrease in the number of perinatally HIV-infected children and a dramatic decline in perinatally-acquired HIV/AIDS cases since There was a sharp decrease in 1993 with a leveling trend from 2002 to 2007, followed by another sharp decrease. In summary, combined, these successful initiatives have resulted in a 95% decline in perinatally-infected births in Florida from 109 cases in 1993 to 6 cases in 2014.
Note: These data represent a 95% decline in HIV-perinatally infected births from 1993 (N=109) to 2014 (N=6). These data include ALL perinatally acquired HIV Infection cases BORN in Florida.
2014 data are provisional. One of the babies born in 2014 have developed AIDS. Data as of 06/30/2015.

52. Living Perinatally Acquired HIV Infection Cases, by County of Birth,
Born in Florida 1979 through 2014
N=833
Number of Cases
1 - 10
> 50
Living Perinatally Acquired HIV Infection Cases, by County of Birth, Born in Florida 1979 through 2014
Florida has 833 living perinatally acquired HIV Infection cases born 1979 through 2014, with the majority (57%) of these cases born in South Florida: Miami-Dade (N=236), Broward (N=134) and Palm Beach (N=101).
Data as of 06/30/2015
A total of 833 perinatally acquired HIV Infection cases born in Florida through 2014 are still presumed to be alive. The majority (57%) of these cases born in South Florida: Miami-Dade (N=236), Broward (N=134) and Palm Beach (N=101) Data as of 06/30/2015

53. Current Age* Distribution of Current Age* Distribution of
Living Perinatally Acquired HIV Infection Cases by Disease Status, Born in Florida,
1979 through 2014 (N=833)
Current Age* Distribution of
Living Perinatally Acquired HIV Infection Cases by Disease Status, Born in Florida 1979 through 2014 (N=833)
Prevalence of perinatally acquired HIV Infection cases in Florida
As of December 31, 2014, there were 833 perinatally acquired HIV Infection cases born in Florida through 2014 and presumed to be living. Their current ages range from 0 to 34 years. Overall, 465 (56%) have developed AIDS. As expected, the majority of the cases under age 13 are diagnosed with HIV (not AIDS) and the majority of cases ages 13 and older have developed AIDS. Access to antiretroviral medications and prophylaxis against opportunistic infections has aided in prolonging the life of many of these perinatal cases.
* Current age of presumed living perinatally acquired HIV Infection cases born in Florida through 2014.
** The vital status for some of the cases born from 1986 or earlier could not be validated therefore some of these presumed living cases may be deceased.
*Current age of presumed living perinatally acquired HIV Infection cases born in Florida through 2014.
** The vital status for some of the cases born from 1986 or earlier could not be validated therefore some of these presumed living cases may be deceased.
Data as of 06/30/2015

54. HIV Infected Newborns 2007 - 2014
ESCAMBIA
OKALOOSA
HOLMES
SANTA ROSA
JACKSON
WALTON
WASHINGTON
NASSAU
GADSDEN
JEFFERSON
HAMILTON
CALHOUN
LEON
MADISON
BAY
COLUMBIA
DUVAL
LIBERTY
SUWANNEE
BAKER
WAKULLA
TAYLOR
UNION
CLAY
GULF
ST JOHNS
FRANKLIN
LAFAYETTE
BRADFORD
ALACHUA
DIXIE
GILCHRIST
PUTNAM
FLAGLER
LEVY
MARION
VOLUSIA
CITRUS
LAKE
Number of Cases
Year of Birth 17
2007 11
2008 9
2009 6
2010 3
2011 8
2012 10
2013
2014
SUMTER
SEMINOLE
HERNANDO
ORANGE
BREVARD
PASCO
HILLSBOROUGH
OSCEOLA
PINELLAS
POLK
INDIAN RIVER
MANATEE
HARDEE
OKEECHOBEE
ST LUCIE
HIGHLANDS
DESOTO
SARASOTA
MARTIN
This map is created by:
Mia L. Rosario, MSW, CCHW
Pediatric Surveillance Coordinator
HIV/AIDS Section – Surveillance Program
Bureau of Communicable Diseases
Division of Disease Control and Health Protection
Florida Department of Health
4025 Esplanade Way
Tallahassee, FL
Office: ext. 3082
GLADES
CHARLOTTE
LEE
HENDRY
PALM BEACH
COLLIER
BROWARD
MONROE
MIAMI-DADE
Data as of 6/30/15

55. Infants Exposed to OR Infected w/ HIV/AIDS
HIV-Exposed Newborns 2014
OKALOOSA 1
HOLMES
ESCAMBIA
SANTA ROSA
JACKSON 1 1 8 2
WALTON
WASHINGTON
NASSAU
GADSDEN 9 1
HAMILTON
CALHOUN
LEON
JEFFERSON
MADISON 41
BAY 3
COLUMBIA
DUVAL
LIBERTY
BAKER
WAKULLA
SUWANNEE
TAYLOR 1 1
UNION
CLAY
GULF
LAFAYETTE 1
FRANKLIN
BRADFORD
ST JOHNS
GILCHRIST
ALACHUA
DIXIE 5
PUTNAM 1 2
FLAGLER 1
Infants Exposed to OR Infected w/ HIV/AIDS
TOTAL Perinatal HIV Exposures  506
Perinatal HIV Infected  6 (1.2% of exposed)
Pediatric HIV (not AIDS)  5 cases
Duval
Escambia
Manatee
Miami-Dade
Orange
Pediatric AIDS 1 case
Palm Beach
LEVY
MARION 5 7
VOLUSIA 2
CITRUS
LAKE
SUMTER
SEMINOLE 4
HERNANDO
ORANGE 42
BREVARD 6
PASCO 4
PINELLAS
HILLSBOROUGH
OSCEOLA
POLK 8 17 49 15
INDIAN RIVER 1
MANATEE
HARDEE 3 2
OKEECHOBEE 2
ST LUCIE 6
HIGHLANDS 4
DESOTO
SARASOTA 2
MARTIN 2
GLADES
CHARLOTTE 46
LEE 10
HENDRY
PALM BEACH
BROWARD 99
COLLIER 1
MONROE
MIAMI-DADE 89 1
Data as of 06/30/2015

56. STEPS TO PERINATAL SUCCESS
Get Prenatal Care
Get an HIV Test
If HIV+, Maintain
Medication Adherence
Keep All Prenatal
Appointments
Follow Up for Mom
And Baby
Ensure Baby Gets
6-weeks of AZT

57. STEPS TO PERINATAL SUCCESS, CONTINUED
Link to Birth Control if that
Is the Client’s Choice
Counsel Against Breast Feeding
Ensure that Baby
Receives HIV testing
By 4 months

58. Perinatal Programs for Women
The Targeted Outreach for Pregnant Women Act (TOPWA) program.
Collaboration with state agencies and organizations to ensure that perinatal HIV issues are addressed.
Perinatal social marketing campaign on Face Book and Twitter
The Perinatal HIV Program” is located on the HIV/AIDS and Hepatitis Program internet site
A Perinatal website through USF that is widely used
Provide 6-weeks of free AZT for newborns of families with no medical coverage
Perinatal Programs:
The Targeted Outreach for Pregnant Women Act (TOPWA) program.
The Florida/Caribbean AIDS Education and Training Center project conducts trainings of perinatal service providers.
The University of Florida project evaluates the perinatal HIV prevention program and conducts chart reviews.
Collaboration with state agencies and organizations to ensure that perinatal HIV issues are addressed.
Perinatal social marketing campaign.
“Women and Children: The Perinatal HIV Program” is located on the Bureau of HIV/AIDS internet site

59. Prolonged Survival--Perinatal New Complications of HIV?
Depression
Feeling of hopelessness
Loss of family members to HIV
Overwhelming burden of illness (appointments, medications, etc.)
Puberty Issues
Short stature, delayed pubertal development
Poor self image
Emotional immaturity/difficulty relating to peers
Sexuality concerns!

60. Prolonged Survival--Perinatal New Complications of HIV?
Increased incidence of cognitive diseases
Learning disabilities
Speech problems
Loss of IQ
Attention Deficit Disorder
Poor attention span/concentration
School failure
Hyperactivity

62. Minor’s Consent for Confidential Health Care
Evaluation and treatment of sexually transmitted diseases (includes HIV in most states)
Family planning, including pregnancy care and contraception (but not abortion usually)
Substance abuse attention
Mental health concerns
Child abuse/domestic violence/sexual assault exams

63. Review of Existing Florida Laws
Minors
Confidential health care permitted for STDs, family planning concerns, substance abuse, and mental health issues (743).
Minors deemed “mature” do NOT need parental consent to be tested for HIV (381), since HIV is considered STD in Florida (384.3).
Informed consent still for HIV testing, but not required to be written (2008 revision).
“Emancipated” minor (743).

64. VOLUNTARY TESTING
HIV testing is voluntary, requiring informed consent.
All people having the test must be told the results.
Exceptions to voluntary testing: Court orders, federal prisoners, military personnel.

65. Number and Percentage of HIV-Infected Persons Aged Engaged in Selected Stages of The Continuum of HIV Care Miami-Dade County, 2013
Definitions
HIV-infected=HIV diagnosed cases divided by 84.2% (to account for 15.8% national estimated unaware of their status in Florida). The 2011 indicator report ( ) estimates that 15.8% are undiagnosed (Table 9a) – this report uses 2010 data and was published in October 2013.
HIV Diagnosed=Number of cases known to be alive and living in Florida through 2013, regardless where diagnosed, as of 06/30/2014 (used for unmet need calculations).
Linked to Care (Ever in Care) =86% of those cases were linked to care, based on persons living with HIV disease in Florida (regardless of where diagnosed) who ever had a CD4 or Viral load (VL) test in the electronic HIV/AIDS Reporting System (eHARS) (2010 National estimates are 79%*).
In Care this Year=55% of cases were in care this year, based on Health Resources and Services Administration (HRSA) unmet need definition, for persons living with HIV in Florida (regardless of where diagnosed) and having at least 1 HIV-related care service involving either a Viral Load or CD4 test or a refill of HIV-related prescription (2010 National estimates for in care are 56%*).
On ART=Estimated 90.6% of In care this year in Florida per 2011 Medical Monitoring Project (MMP) data (2010 National estimates are 80%*).
Suppressed VL=Estimated 78.0% on ART & a suppressed VL (<200 copies /mL) this year in Florida per 2011 MMP data (2010 National estimates are 70%*). *Continuum of HIV care among Ryan White HIV/AIDS Program clients, U.S., (
(1) Number of cases known to be alive and living in Florida through 2013, regardless where diagnosed, as of 06/30/2014 (used for unmet need calculations).
(2) Ever in Care = 86% of those cases were linked to care, based on persons living with HIV disease in Florida (regardless of where diagnosed) who ever had a CD4 or Viral load (VL) test in the electronic HIV/AIDS Reporting System (eHARS). (2010 National estimates are 79%*).
(3) 55% of cases were in care this year, based on HRSA unmet need definition, for persons living with HIV in Florida (regardless of where diagnosed) and having at least 1 HIV-related care service involving either a VL or CD4 test or a refill of HIV-related RX. (2010 National estimates for in care are 56%*).
(4) Estimated 90.6% of In care and on ART this year in Florida per 2011 MMP data (2010 National estimates are 80%*).
(5) Estimated 78.0% on ART & the viral load is <200 this year in Florida per 2011 MMP data (2010 National estimates are 70%*). *Continuum of HIV care among Ryan White HIV/AIDS Program clients, U.S., (
For additional information please refer to the Florida Continuum of Care slide set accessible at

66. The primary goal of the initiative – to reduce HIV transmission – is not new. Advancing HIV Prevention emphasizes the use of proven public health approaches to reduce incidence and the spread of disease. The initiative consists of four priority strategies:
Make voluntary testing a routine part of medical care.
Implement new models for diagnosing HIV infections outside medical settings.
Prevent new infections by working with persons diagnosed with HIV, and their partners, and
Further decrease perinatal HIV transmission.
<click> This presentation will focus on two of these strategies, related to HIV screening in healthcare settings:
Making voluntary testing a routine part of medical care, and further reducing perinatal transmission.

67. It is estimated that sexual transmission accounts for 32,000 of the 40,000 new infections each year.
Conservative estimates based on the changes in behavior observed once people find out they are infected with HIV indicate that the 25% of people who are unaware that they are infected account for at least 54%, and potentially as much as 70%, of the new sexually transmitted infections each year. The transmission rate among those who don’t know they are infected is 3.5 times higher than for people who know about their HIV infection.
The importance of getting these individuals tested and into care that includes both treatment and prevention interventions is critical.

68. Improving Prevention for Youth
Continued school-based risk reduction education (including abstinence information).
Encouraging HIV testing (prevention education opportunity).
Greater efforts to reach out-of-school youth (drop-outs, homeless/runaway, juvenile offenders).
Targeted efforts toward young gay/bisexual males, including PrEP.
Attending to STD treatments and condom availability.
Assuring Hepatitis B and HPV immunizations.
Partnering with community-based programs.
Integrating with substance abuse programs.
Sustained efforts!

69. Contact: (850) 245-4444 Lorene Maddox, MPH Ext. 2613
For Florida HIV/AIDS Surveillance Data
Contact: (850)
Lorene Maddox, MPH Ext. 2613
Tracina Bush, BSW Ext. 2612
Julia Fitz, MPH Ext. 2373
Internet
Intranet
CDC’s Internet site for HIV/AIDS Slides:
adolescents2007.ppt
For Florida HIV/AIDS Surveillance Data
Contact: (850)
Lorene Maddox, MPH Ext. 2613
Tracina Bush, BSW Ext. 2612
Julia Fitz, MPH Ext. 2373
Internet
Intranet
CDC’s Internet site for HIV/AIDS Slides:

70. RESOURCES CDC Website: www.cdc.gov
HRSA HIV/AIDS Bureau:
FL DOH:
NIH/NIAID: www3.niaid.nih.gov/topics/HIVAIDS/
Kaiser Family Foundation:
Advocates for Youth: