HIVAIDS: Modes, Models, and Mitigation

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HIV/AIDS Modes, Models, and Mitigation
COA Scientific Symposium, June 07 CDR Scott
Giberson, PH-C, RPh, MPH National HIV/AIDS
Principal Consultant, IHS
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Objectives

• Provide an update of HIV/AIDS epidemiology
  globally and in the US
• Illustrate transmission modes, public health and
  ecological models via discussion of a
  comprehensive HIV/AIDS Program
• Discuss HIV risk, vulnerability, and similarities
  of indigenous populations
• Enumerate and discuss prevention / mitigation
  models and strategies.

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• I am an invisible man invisible understand,
  simply because people refuse to see me
• Ralph Ellison, 1952

• 64.9 million people infected with HIV
• since the pandemic began
• 39.5 million (34.147.1 million) PLWH/A
• Will be 3rd leading cause of death in roughly
• 10 years. Why does HIV become even more
• critical?

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Worldwide Incidence and Prevalence

• Total 4.3 million (3.66.6 million) new
  infections in 2006
• Total deaths in 2006 2.9 million
• HIV/AIDS is the fourth (set to be third) leading
  cause of death globally, but leading cause age
  20-24
• 4.9 million new HIV infections (2004)
• 5 million new HIV infections (2006)

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Worldwide Prevalence Estimates

• 15-34
• 5-15
• 1-5
• 0.5 1
• 0.1-0.5
• lt 0.1

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Gender Differences by Area
Suggestive of transmission categories and models
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HIV/AIDS in the US

• Est. 850-950K PLWH/A
• Est. 24 unaware
• Incident cases 40,000
• Deaths16,000
• - both have remained relatively stable since
  1998
• Incidence increased 14 among MSM and 10 among
  heterosexuals.
• Perinatal 100 cases /yr

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HIV/AIDS in the US
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HIV/AIDS in the US
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HIV/AIDS in the US
Ages 20 - 49
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Modes of Transmission
MSM and IDU 14
Hetero32
MSM 49
IDU 4
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Modes of Transmission
MSM and IDU 14
Hetero32
MSM 49
IDU 4
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Transmission Modes and Models

• 4 modes of transmission
• Blood
• Semen
• Vaginal fluid
• Breast milk
• Global models reflect modes of transmission,
  epidemiology and higher risk groups
• African Model vs Asian Model
• US Model? Half-full or half-empty

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Models of Intervention

• Treatment Centered
• greater impact on short and near-term mortality
• can enable more effective prevention
• data modeling 10 increase in infections and
  9-13
• reduction in mortality within 5 years1
• Prevention Centered
• greater impact on incidence
• long-term mortality trend more favorable
• data modeling 36 reduction in infections and
  mortality
• reductions are similar treatment-centered
  model after
• 10-15 years1
• Variable results based on current prevalence

1. Salomon et al, Jan 2005
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Impact of Models

• Demonstrates the importance of epidemiology,
  transmission modes, and mitigation models
• Given limited resources, budgets can be directed
  in the most appropriate way
• In the long term, both preventive and combination
  strategies will reduce resource needs for
  treatment
• Effective treatment as preventive strategy
• Comprehensive strategies are most effective both
  in theory and in practice.

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Comprehensive HIV/AIDS Program Model (Priority
Areas)
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Indigenous Populations Vulnerabilities

• Access to health services
• Resource-constrained settings
• Mobile populations
• Health is interwoven with culture
• Tradition may suppress open discussion or
  implementation strategies
• Socioeconomic may affect impact
• Lack of indigenous workforce
• Health disparities

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Global Contexts of Vulnerability

• Governments Policy
• Socio-economic status
• Spirituality
• Gender / Youth
• Culture
• Challenges of a Cultural Approach

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Specific AI/AN Similarities

• Health not just physiological
• Wellness rooted in spirituality and culture
• Unique govt to govt relationship and Hx
• Health status is a linkage between all sectors of
  influence
• Socio-economic status
• Youth of the population
• Participation of AI/AN in all programs is
  necessary for success
• Health disparities and contexts of risk
• Culture has influence over behavior

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Co-Factors of HIV Risk
STD Rates / Sexual behavior
? HIV Risk
Substance Use
Violence/Abuse
Health Disparities, stigma, access, social norms
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Intervention Model
Broad sociocultural / traditionalism/ spiritual
Constructed Environment
Community
Clinical / Facility
Individual
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Implementation Barriers in
Resource-Constrained Settings

• Stigma in facilities and communities
• Jurisdiction in certain situations
• Lack of open discussion and education at all
  levels
• Lack of human resources with expertise
• Appropriate but competing priorities.
• Complacency ( of cases in US, effect of ARV)
• Gathering data remains complex
• Complexity of treatment and care
• Challenges of developing targeted intervention
  for
• coverage of vulnerable, hard-to-reach groups

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Proven Mitigation/Prevention Strategies

• Increase knowledge of status
• Changes behavior
• Credible Prevalence
• CDC recommendations (NEW as of 09/2006!!)
• Education/Outreach
• Peer Intervention
• Integrate with other prevention messages
• Client-centered, interactive sessions
• What about school sex-education?

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More Prevention / Mitigation

• Behavior Change
• Normalize HIV
• High risk groups targeted
• BCC tailored to culture
• Multiple sessions
• Harm Reduction
• Effective Treatment as prevention (3 ways)
• Prevent MTCT (augmented by knowledge of status
  prior to conception)

Combined outcomes from multiple evidence-based
reports (includes CDC, WHO, other Syringe
Exchange data based on MMWR 2005 54(27)
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New Prevention Technologies

• HIV vaccines
• Vaginal and rectal Microbicides (discussed
  earlier)
• Adult male circumcision
• Treatment of other STIs
• Pre-exposure prophylaxis (PrEP) using
  antiretroviral drugs

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Critical Conversation

• Is the ABC method working?
• HIV/AIDS as a chronic disease
• Two biggest concerns regarding HIV/AIDS
• Affects younger population
• Tied mostly to sexual behavior
• Sex education and harm reduction how can we be
  more effective within these interventions?

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Recommendations

• Routinize and Normalize HIV testing services
• Reduce stigma and discrimination
• Support testing and knowledge of status
• Integrate HIV message in all other appropriate
  health promotion messages
• Behavior component integrated in primary care
• Adoption of indigenous perspective and workforce
• Utilize evidence-based strategies - focus on
  outcomes
• Dont be complacent

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During this 30 minute lecture, 280 people
acquired HIV and roughly 170 people died of AIDS
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• HIV/AIDS is arguably the most critical global
  health issue of our generation. As leaders in
  public health, let us not be by-standers in the
  fight

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Thank you.Questions?
IHS HIV/AIDS Homepage www.ihs.gov/medicalprograms
/hivaids/
COA Scientific Symposium, June 07 CDR Scott
Giberson, PH-C, RPh, MPH National HIV/AIDS
Principal Consultant, IHS