MIC test 1 lecture 10 (9/26) Flashcards

• 7 mil ppl with HIV in 2020. Steady number
• Aquired in 2020 – 1.5 million
• Ppl dying from HIV related causes – 680,000
• Talked abt the 90-90-90 goal for 2020
  • In 2019, had 81% ppl knowing of their HIV infection
  • 67% on treatment who know their disease status
  • 59% of those ppl achieved viral suppression

• Populations at risk = MSM = men who have sex with men, African americans

Est HIV incidence

• Demographic % of population in the US compared to their propotion of having HIV among the groups
  • Ex: whites are 62% of the population but make up 25% of the HIV cases
  • African americans/blacks are 12% of population, but represent 42% of HIV cases in the US

20,000 of 38,000 are MSM

• majority are black/aferican american individuals

younger ppl dominate - most affected population (25-34 yrs)

• miami area - highest rate per population (btw 20-43 / 100,000)
• average of US = 12 per 100,000
• miami dade county - epicenter

• linkage to care
• retention in care
• viral load suppression

pic shows linkage to care within 1 month of HIV diagnosis

darker color = worse

florida is actually better, but still not where want

ability to keep ppl in care at least 2x per year

darker color = worse

better in florida, midsection of US worse

viral suppression = 200 copies virus/ml (want ppl to be <20 copies now)

darker colors worse

florida not very good in this one (only 62-66% on ARV therapy are suppressed)

some states are bad in all 3

editorial talking abt plan for ending HIV epidemic

• involved all divisions of of health + human services. mostly led by NIH/CDC

FOUND:

• of 3007 counties in the US, over 50% of of HIV infections were in only 48 of these counties
• majority of infections among black/african american and hispanic/latino MSM, high incidence among trans + ppl who use intravenous drugs
• 7 mostly southern states have disproportionate occurrence of HIV in rural areas

wanna focus on these areas to make biggest impact

how to do that? see next card

75% in HIV infections in 5 years and at least 90% reduction in 10 years

• ambitious goal

sits on 4 pillars:

1. diagnose all ppl w/ HIV as early as possible
2. treat the infection rapidly + effectively to achieve sustained viral suppression
3. protect ppl at risk of HIV using potent and proven prevention and interventions, including PrEP, a medication that can prevent HIV infections
4. respond rapidly to detect and respond to growing HIV clusters and prevent new infections

1998 - right after started using combination ARV therapy

used to treat ppl depending on their CD4 cell level, now, treat EVERY INFECTED PERSON POSSIBLE

in 2012, started treating everyhing HIV+ who was willing to take treatment

• now treat right away (earlier than before)
• this change happened bc some things
  • before didnt know all side effects, of resistent, etc.

this changed bc of 052 study that came out (next card)

prevention study

looked at couples where 1 had HIV and 1 did not

randomized control - treatment given to 1 partner

• showed no linked infections when HIV suppressed by ARV therapy

= suppression is critical to transmission (undetectable = untransmittable)

= realized should treat ppl early to prevent transmission

to show whether if start therapy early, compare to started later, does this make better outcome for person?

individual with higher CD4 count had better outcome

primary event cane = death, heart attack, etc.

treat ppl early = prevent time to the first primary event

confirmed early treatment better than waiting

(now know dont just prevent transmission, but allows individual to DO BETTER)

88% ever in care drop 20% (difference) to 69% in care

in care/retained = small difference (69 vs 64%)

and can usually suppress - only 58% of all people living with HIV are virally suppressed

where can make biggest impact? by retaining ppls + getting them into care

tried to get ppl treatment quickly after diagnosis

results indicated that ppl able to be taken into care around same day were able to be suppressed

san francisco did same thing

• had clinics where if someone diagnosed w/ HIV -> would sent them same day directly into care so they get started on ARV therapy

doing it early - can suppression quicker = great benefit so can decrease transmission

what did this mean for viral load suppression? and impact on our ability to keep them in care?

traditional linkage to care pathway (L)

high acceptability in 1st year

2016 Dr. Hansel worked to get infectious disease elimination act (IDEA) passed at state level

• approved + miami made needle exchange program. very successful
• gives out needle exchange
• decreased # deaths in miami-dade county

cohort of individuals who tested positive

none got it from eachother, but from other means

important at this time:

• were doing test + treat program
• dr. hansel -> insidivuals diagnosed immediately started on ARV therapy when diagnosed

70 days

also brought ppl who fell out of care back in

• give ppl treatment to prevent transmission of HIV before get HIV

used dual drug - gave in randomized control trial

• either durg or placebo to high risk men

found preexposure prophylaxis DOES prevent HIV aquisition

blue = less aquisition (y axis) compared to placebo (almost 40% difference)

didnt know how to make it more effacacious

• will MSM want PrEP?
• how will MSM use PrEP?
• how will sexual practices change?
• will PrEP be safe in the real world?

= questions in 2012

US PrEP demonstration project

• aids czar contacted kolber + asked if wanted to participate in project in san fransisco regarding PrEP in real world

NIAID funded PrEP demonstration project

multi site prospective openlabel

wanted to look at 500 at risk individuals in real world setting (MSM and trans women)

offered up to 48 weeks of prEP

in 3 places

• san fransisco city clinic
• STD clinic in miami
• whitman walker clinic

methods

• HIV neg MSM and trans women enrolled oct 2012-jan 2014
• behavioral risk criteria:
  • condomless anal sex w/ 2+ partners
  • 2+ episodes of anal sex w/ HIV+ partner
  • syphylis, rectal gonorrhea, or chlamydia diagnosis
• no serious medical conditions
• offered up to 48 weeks of drug
• follow up

found: graph attached

last time gave meds was week 36 (dont count wek 48)

• all consistent and ok except miami (dropped off quick at first then consistent)
  • miami hispanic + younger than other pops
• miami worse at staying on meds

effectiveness/ability to prevent HIV varies a lot

• bc drug level correlates to efficacy

figure:

• x axis - concentration of drug
• y axis - HIV incidence
• blue line = hiv incidence as function of concentration
• abrs reperesent how concentration as function of how many times take it
• only 2x per week = significantly higher hiv incidence than taking it 4 or 7x per week

substantial risk of HIV infection

• MSM
  • HIV+ sexual partner
  • recent bacterial STI
  • high # sex partners
  • history of inconsistent/no condom use
  • commercial sex work
• heterosexual women/men
  • HIV+ sexual partner
  • recent bacterial STI
  • high # sex partners
  • history of inconsistent / no condom use
  • commercial sex work
• IDU (intravenous drug use)
  • HIV+ injection partner
  • sharing injeciton needles

darker = worse

• florida is bad - not a lot of coverage fopr PrEP

1.1 million individuals in UN at risk for HIV and should be offered PrEP

estimated number of PrEP users end 2018 = 269,000

being PrEPared

• stigma + distrust of medical system prevent at risk ppl of color from obtaining + benefiting from PrEP
  • remember, they are the ones who seem more likely to get it

44% ppl who could benefit are african american (500K)

only 1% of those (7K) wre prescribed PrEP

25% ppl who could benefit from PrEP are latino (300K)

only 3% of them (7600) prescribed it

overcoming prep adherence problems

need to masintain good drug levels for protection

prep presistence - do ppl stay on or get fatigued?

e

repeated goals again (75% in 5 years and 90% in 10 years)