1. High Impact Prevention and the Future of the HIV Epidemic in the United States Jonathan Mermin, MD, MPH Division of HIV and AIDS Prevention, NCHHSTP Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

2. Overview  State of the U.S. HIV Epidemic  HIV Prevention Goals of the National HIV/AIDS Strategy  High Impact Prevention in Theory  High Impact Prevention in Practice  Signs of Improvement and Continued Challenges

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

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

5. 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

6.  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

7. Stall, AIDS and Behavior 2009. 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

8. National HIV/AIDS Strategy: Achieving the Prevention Goals 8

9.  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

10. Adapted using methods from Hall, et al. JAIDS 2010 Reducing incidence by 25% In 10 years would prevent 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 prevent 62,000 infections and save $23 billion In 5 years would prevent 109,000 infections and save $42 billion Achieving the NHAS Incidence Goal An essential first step – but bolder action needed NHAS: Achieving the Prevention Goals

11. President’s FY2013 HIV Budget Request Adjusting for inflation, no increase in domestic HIV prevention budget over past decade Holtgrave J Urban Health 2007; Kaiser Family Foundation U.S. Federal Funding for HIV/AIDS: The President’s FY 2013 Budget Request; Bureau of Labor Statistics NHAS: Achieving the Prevention Goals

12. High Impact Prevention in Theory

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

14.  Simply combining interventions is not enough  All interventions are not effective  All effective interventions are not equal Limited Resources Demand Difficult Decisions High-Impact Prevention in Theory

16. High Impact Prevention in Practice 16

17. 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

18. 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

19.  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

20.  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

21.  Care and Prevention in the United States (CAPUS) demonstration projects  $14.5 million annually over 3 years for services targeting racial and ethnic minorities in 6-9 states  Improve diagnosis, linkage, retention, ART provision, viral suppression, and behavioral prevention, using individual and community-level surveillance data  Provide information to patients and clinicians addressing social and structural issues High Impact Prevention Fights Inequities High Impact Prevention in Practice

22. MMWR December 2011; NYC Dept. of Health and Mental Hygiene, The New York City A1C Registry fact sheet  Public health responsibility to close gaps in HIV care and prevention services  Currently only 28% 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  Opportunity to emulate successful programs in other disease areas  Example: hemoglobin A1C registry and diabetes monitoring in New York City Strengthening the Public Health Approach to HIV High Impact Prevention in Practice

23. Moupali D et al. (2010). PLOS One 5 (4): e11068 Success in San Francisco Community Viral Load and HIV Incidence High Impact Prevention in Practice

24. Signs of Improvement and Continued Challenges

25. Americans who have been tested for HIV MMWR June 2009; MMWR March 2012; HIV Surveillance Report 2010 Signs of Improvement and Continued Challenges AIDS diagnosis within 12 months of initial HIV diagnosis 2009: 45% 2006: 40% 1996: 43% 2009: 32%

26. Awareness of HIV infection among MSM in 20 cities, United States NHBS preliminary data for 2011 and MMWR 2010;59(37):1202-7 Signs of Improvement and Continued Challenges

27. MSM taking antiretroviral therapy among those aware of infection in 20 cities, United States NHBS preliminary data for 2011 and MMWR 2010;59(37):1202-7 Signs of Improvement and Continued Challenges

28. CDC. MMWR 2012;61(Suppl; June 15, 2012):57-64. Holtgrave et al. Updated Annual HIV Transmission Rates in the United States, 1978-2006. J Acquir Immune Defic Syndr 2009;50(2):236-38; Holtgrave et al. HIV Transmission Rates in the United States, 2006-2008. The Open AIDS Journal 2012;6:20-22. HIV Testing Initiatives Effective but HIV Epidemic Continues to Grow Signs of Improvement and Continued Challenges

29. Conclusions  Growing number of people with HIV and restricted budget require higher impact strategies  Act swiftly as window for success may be closing  Large disparities require conscious application of health equity approaches  Powerful tools and enhanced understanding  Integrate public health prevention, care, and surveillance programs

30. Acknowledgements Michelle Bonds Amy Stone Amy Lansky Irene Hall Gabriela Paz-Bailey Janet Cleveland Stephanie Sansom Findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC or persons acknowledged in this slide