Chartbook on Effective Treatment

Overview

• HIV is a virus that kills or damages cells of the body's immune system.
• AIDS is the most advanced stage of HIV infection.
• HIV can be spread through:
  • Any unprotected sex with an infected person.
  • Sharing of drug needles.
  • Contact with the blood of an infected person.
• Women with HIV can pass the virus to their babies during pregnancy, childbirth, or breastfeeding.

Impact of HIV and AIDS

• The impact of HIV infection and AIDS is disproportionately higher for:
  • Racial and ethnic minorities.
  • People of lower income or education levels.
  • Other vulnerable populations with high-risk behaviors, such as transgender people.
• Although access to care has improved, several groups of people with HIV remain less likely to have access to care and less likely to have optimal patterns of care:
  • Blacks and Hispanics.
  • Women.
  • Injection drug users.
  • Homeless people.
  • Uninsured people (Moore, 2011).

Prevalence and Incidence of HIV Infection

• The Centers for Disease Control and Prevention (2015c) estimates that:
  • More than 1.2 million people age 13 years and over are living with HIV infection.
  • About 12.8% of people with HIV are unaware of their infection.
  • The number of people living with HIV has increased, while the number of new infections has remained fairly stable, at about 50,000 per year.
  • The rate of new infections is high among certain groups, such as men who have sex with men (MSM).

Diagnoses of HIV Infection by Race/Ethnicity

• In 2013, the total number of diagnoses of HIV infection in the United States was 47,352 (CDC, 2015d).
• The 2013 rate of diagnosis of HIV infection¹ per 100,000 population² follows (CDC, 2015d):
  • Whites, 6.6.
  • Blacks, 55.9, approximately 8 times the rate of Whites.
  • Hispanics, 18.7, approximately 3 times the rate of Whites.
  • Multiple-race individuals, 16.8, approximately 2.5 times the rate of Whites.
  • Native Hawaiians and Other Pacific Islanders (NHOPIs), 12.7, approximately twice the rate of Whites.
  • American Indians and Alaska Natives (AI/ANs), 9.4.
  • Asians, 6 per 100,000.

Diagnoses of HIV Infection by Transmission Category

• In 2013, HIV infections among adolescents and adults in the United States were attributed to the following (CDC, 2015d):
  • Male-to-male sexual contact, 65%.
  • Heterosexual contact,³ females, 17%.
  • Heterosexual contact, males, 8%.
  • Injection drug use, males, 4%.
  • Injection drug use, females, 2%.
  • Male-to-male sexual contact and injection drug use, 3%.
  • Other transmissions,⁴ <1%.

HIV and AIDS Among MSM

• In 2013, in the United States, gay and bisexual men accounted for 81% (30,689) of the 37,887 estimated HIV diagnoses among all males age 13 years and over and 55% of the estimated number of people diagnosed with AIDS among all adults and adolescents in the United States (CDC, 2015a).
• Of the estimated 14,611 gay and bisexual men diagnosed with AIDS, 40% were Black, 32% were White, and 23% were Hispanic (CDC, 2015a).
• MSM represent only 2% of the U.S. population but:
  • Is the only risk group in which new HIV infections have been gradually increasing since the 1990s.
  • Have constantly represented the largest percentage of people diagnosed with AIDS and people with an AIDS diagnosis who have died (CDC, 2015a).
• In 2011, in the United States, among MSM with diagnosed HIV infection:
  • 80.6% were linked to care.
  • 57.5% were retained in care.
  • 52.9% were prescribed antiretroviral therapy (ART).
  • 44.6% had achieved viral suppression (CDC, 2015a).

HIV and AIDS Among Transgender People

• Transgender people have been significantly affected by the HIV/AIDS epidemic in the United States.
• Transgender women have the highest risk of HIV infection:
  • HIV prevalence in transgender women is an estimated 21.7% (Baral, et al., 2013).
  • Among male-to-female (MTF) people, 27.7% tested positive for HIV infection, but 11.8% self-reported being HIV positive (CDC, 2015b).
  • Higher HIV rates (56.3% for test results and 30.8% for self-reporting) were found among MTF Blacks (Herbst, et al., 2008).
  • By race/ethnicity, Black transgender women have the highest percentage of new HIV-positive test results.
• Transgender people often engage in behaviors that increase the risk of HIV infection, such as:
  • Multiple sex partners or unprotected sex.
  • Commercial sex work, and
  • Use of needle injections for recreational drugs or to alter gender (e.g., hormones, silicone) (Herbst, et al., 2007; Stephens, et al., 2011).
• Limited data make creating evidence-based HIV prevention interventions that meet the unique needs of transgender populations challenging, so it is imperative to collect data on transgender people.

HIV and AIDS Among People Who Inject Drugs

• Injection drug use leads to approximately 10% of HIV cases in the United States annually (AIDS.gov, 2014).
• Injection drug users can get and spread HIV by:
  • Sharing drug preparation or injecting equipment with a person who has HIV.
  • Engaging in risky sexual behaviors with their sex and drug-using partners.
• About 80% of HIV-infected injection drug users in the United States also have hepatitis C (HCV) (AIDS.gov, 2014):
  • HCV leads to cirrhosis of the liver and liver cancer.
  • HCV is more serious in people living with HIV because it leads to liver damage more quickly.
  • Co-infection with HCV also affects treatment of HIV infection, making it important for people who inject drugs to know if they are infected with HCV and to continue to protect themselves.

HIV and AIDS Policy

• The White House Office of National AIDS Policy launched the National HIV/AIDS Strategy in July 2010 (ONAP, 2010):
• Comprehensive plan focused on (1) reducing the number of people who become infected with HIV, (2) increasing access to care and optimizing health outcomes for people living with HIV, and (3) reducing HIV-related health disparities.
• Roadmap for policymakers, partners in prevention, and the public.
• In 2013, the President launched the HIV Care Continuum Initiative, which outlines strategies to optimize health outcomes for those living with HIV.
• In 2014, funding through the HHS Secretary's Minority AIDS Initiative Fund and the Affordable Care Act helped strengthen the capacity of community health centers to identify and treat HIV.
• The Affordable Care Act provides better access to health care coverage and more health insurance options for people living with HIV (AIDS.gov, 2014).

HIV and AIDS Measures

• Outcome: New AIDS cases.
• Process: Adult HIV patients who had at least two outpatient visits during the year.
• Outcome: Adult HIV patients with a viral load less than 200 copies/mL.
• Outcome: HIV infection deaths.
• Two measures from the Ryan White HIV/AIDS Program:
  • Outcome: HIV patients in Ryan White-funded care who were virally suppressed (HIV RNA <200 copies/mL).
  • Process: HIV patients in Ryan White-funded care who were retained in care (at least two ambulatory visit dates 90 days apart).
• One measure is not included in the 2014 reports due to statistical issues:
  • Adult HIV patients who received antiretroviral therapy.
• One measure reached the 95% ceiling and is no longer reported⁵:
  • Eligible patients receiving prophylaxis for Pneumocystis pneumonia.
• Two measures were removed due to changes in HIV care guidelines (http://aidsinfo.nih.gov/guidelines):
  • Adult HIV patients who received two or more CD4 tests during the year.⁶
  • Eligible patients receiving prophylaxis for Mycobacterium avium complex.⁷

^1. Data include people with a diagnosis of HIV infection regardless of stage of disease at diagnosis.

^2. 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.

^3. Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection.

^4. Other transmission categories include hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

^5. Measures that reach performance levels of 95% are no longer reported. Data on these measures will continue to be collected and these measures will be added back to the reports if their performance falls below 95%.

^6. The treatment guideline for clinical practice in the past was generally to monitor both CD4 T lymphocyte (CD4) cell count and HIV RNA (viral load) concurrently, as markers of the response to ART and HIV disease progression. However, a new recommendation requires the initiation of ART for all HIV-infected individuals regardless of their viral load or CD4 count, weakening the rationale for frequent CD4 monitoring. When a patient is on ART, CD4 count is not useful as it will not guide changes in treatment, according to the U.S. treatment guidelines (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2015). In addition, reducing the frequency of routine CD4 testing in patients who are virally suppressed can save an estimated $18 million annually, which can be redirected to other HIV care services (Hyle, et al., 2014).

^7. Prophylaxis for Mycobacterium avium complex (MAC) is not required among patients receiving ART who are virally suppressed. Studies show that eliminating MAC prophylaxis could reduce pill burden and the risk of drug-drug interactions, along with adverse treatment effects (Yangco, et al., 2014). With ART, patients can achieve viral suppression and healthy CD4 counts and prevent the onset of secondary infections such as MAC (Buchacz, et al, 2010). Thus, we do not track specific MAC prophylaxis.

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