Following up on their latest report showing the devastating and growing impact of HIV among black gay and bisexual men, especially young men who sex with men, the Centers for Disease Control and Prevention held a conference Aug. 15-16 in Atlanta to discuss the latest research. The CDC also previewed a new campaign aimed at increasing HIV testing and awareness since the CDC estimates that a very high percentage of MSM are unaware of their HIV status.
The "Testing Makes Us Stronger" campaign will also do considerable outreach on Facebook and other social media. The campaign is part of a $45 million, five-year initiative launched by the White House in 2009. On Aug. 3, the CDC released its new estimates of the annual number of new HIV infections in the US from 2006 through 2009. While the CDC says the overall numbers “relative stability” at around 50,000, they also show the continued disproportionate impact on black gays and bisexuals.
“But the most concerning aspect of the new estimates is the finding that new HIV infections among young black MSM increased by an alarming 48 percent during the four-year period 2006 to 2009. And this group, young black men who have sex with men, age 13 to 29 years, was the only group in the United States to experience significant increases during that time,” said Dr. Kevin Fenton, the CDC Director for HIV/AIDS and STD Prevention, on an Aug. 15 conference call with reporters. “These new analyses underscore the urgency of reaching young black men who have sex with men with HIV prevention. We cannot allow the health of a new generation of young, black gay and bisexual men to be lost to essentially preventable diseases.”
HERE ARE THE TRANSCRIPTS FROM THE TWO CDC CALLS WITH REPORTERS ON THE NEW CAMPAIGN AND THE NATIONAL STRATEGY ON AIDS
CDC Conference Call Transcript on Aug. 15, 2011:
Monday, August 15 at 12:30 p.m. EDT
WHO: Kevin Fenton, M.D., Ph.D., Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), CDC
Richard Wolitski, Ph.D., Deputy Director, Behavioral and Social Science, Division of HIV/AIDS Prevention (DHAP), CDC
- Previewing an upcoming CDC campaign to increase HIV testing and awareness among black MSM
John Su, M.D., Ph.D., Medical Epidemiologist, Division of STD Prevention, CDC
- Presenting results of the first national assessment of the prevalence of HIV co-infection among individuals diagnosed with syphilis in the United States
Susan Kegeles, Ph.D., Co-Director, Center for AIDS Prevention Studies, University of California at San Francisco
- Presenting results of a new study examining the specific individual, social, and structural factors that are associated with HIV risk behavior among young, black MSM
Gregorio Millett, Senior Scientist, DHAP, CDC
- Discussant: Drivers of the epidemic among black MSM and the National HIV/AIDS Strategy
Kali Lindsey, Senior Director of Federal Policy, Harlem United Community AIDS Center
- Discussant: Perspectives from the front lines and expert advisor to CDC’s upcoming HIV testing campaign for black MSM
FENTON: Dr. Su, thank you so much for giving us this brief overview of trends in HIV and syphilis among men who have sex with men, and the intersection between these epidemics among men who have sex with men. Dr. Kegeles, I understand that you have done some research that might offer some research into the whys, why we are seeing these increases in these infections and perhaps on the overlap between these infectious diseases.
SUSAN KEGELES: Right, thank you, Dr. Fenton. We—my team and I have been conducting research in Dallas and Houston, and we have a sample of over 650 young gay and bisexual men aged 18 to 29. And so we were looking in this study at issues about why young gay and bi men were having unprotected sex, and we found that contextual issues played important issues—the context of young black men’s lives. And so some of the things that we found that were associated with having unprotected sex was low education, poverty, a history of homelessness, history of racism within the last few months, and having been incarcerated before, 1/3 of the sample had been incarcerated before.
But we found that other social factors were also important, including social support from gay and bisexual friends, the social norms about being safe, and homophobia—hearing homophobic comments made to them in the recent past. But we also—this was analysis of looking at multi-level issues, trying to understand what issues were related to sexual risk behavior. And we found individual level issues as well. Depression—the more depressed a young man was, the more likely he was to have unprotected sex. His beliefs in whether or not he really can enact safer sex was related, poor condom use attitudes, which makes sense, of course. But also low gay pride and internalized homophobia, so the worse you felt about yourself as a gay man, the more likely you were to be having unprotected sex.
So some of the causes of unprotected sex are the same for young black men as they are for other young gay and bisexual men, but some of them are quite different, when you think about the context of being black in our society. So they’re dealing both with the structural issues of being black in our society, and being young black men is very difficult. And then being black gay and bisexual men living within the black community, most of them stay within their community of origin, they don’t move away, as many white men do. And so they continue to hear some of the homophobia from their own community. And these all then lead men to being more unsafe.
FENTON: Great. Thank you very much, Dr. Kegeles. Now your study is a very powerful reminder of the difficult challenges facing young black gay men in the United States, and I think the findings clearly remind us that the solutions for this population are certainly not going to be simple, and they underscore the need for action at so many levels, something that I’m very passionate about looking at, that multi-layered response to the epidemic, especially among young gay and bisexual men. We need to be focusing at the individual level, at the family level in communities across the country and certainly looking at the societal level, laws and policies, governance that can really help our prevention efforts with this group.
Now, there are further issues that we can explore, and we will be exploring with our other panel members this afternoon to hear more about what we know about how we should be addressing some of these multi-layered challenges within the population of black, gay and bisexual men in the United States. And perhaps most importantly, how we can be more effective in building resilience and strength within this particular community in the United States.
Now, one effort underway is to equip young black men who have sex with men with critical knowledge to help protect themselves and encourage more frequent HIV testing. And this is a new CDC—this is the aim of a new CDC campaign under development, which is aimed at increasing HIV testing and awareness among black men who have sex with men. The campaign is called “Testing Makes Us Stronger.” It is part of CDC’s act against AIDS campaign, and was developed after extensive formative research with a campaign audience. Now during three rounds of research, we conducted in-depth interviews and surveys with almost 400 black men who have sex with men, living in various cities across the country. We asked questions of these men to better understand the factors that might influence HIV testing and looking at effective channels for placing campaign materials, and we tested the messages and creative concepts with these men to develop materials that would be most effective for black men who have sex with men.
Now we have Dr. Wolitski here from CDC’s division of HIV/AIDS prevention, and Dr. Wolitski, could you please tell us a little bit more about the campaign?
RICH WOLITSKI: Of course, I’d be happy to. CDC’s division of HIV/AIDS prevention supports a wide range of efforts that have provided critical data on the health and the risk of young black men who have sex with men. They’ve led to the development of new interventions for black men who have sex with men, and we’ve supported the implementation of effective interventions for this population by health departments and community-based organizations around the country.
This work includes the research with black men who have sex with men that Dr. Kegeles just described, as well as projects that have evaluated the most effective ways to make HIV testing available to black MSM and to develop and test more effective interventions for this population. A summary of these activities is available on the CDC Web site, and we have copies of this information available here today. But we know that these efforts are not at the scale that they need to be, and from what we’ve heard today, it’s clear that we need to intensify HIV prevention for black men who have sex with men. HIV testing is one critical key component of prevention services that are needed for this population.
People who know that they have HIV can take steps to decrease the risk that they’ll transmit the virus to others, such as adopting safer sex practices, and beginning anti-retroviral treatment. The need for greater testing among black MSM is clear. A 2008 CDC study of gay and bisexual men in 21 major U.S. cities found that of those black MSM who were HIV positive, more than half—59 percent—were unaware of their infection. That’s far more than MSM of any other race. I’m pleased today to preview “Testing Makes us Stronger,” a new CDC campaign for black gay bisexual and other men who have sex with men.
“Testing Makes Us Stronger” is a part of the act against AIDS campaign, a five-year, 45 million dollar initiative that was launched by the White House in 2009 to fight complacency about HIV in the United States. Act against AIDS supports a number of campaigns ranging from national awareness campaigns to more targeted campaigns for more high-risk populations. Details about all of the act against AIDS campaigns are available at our Web site at actagainstaids.org.
“Testing Makes Us Stronger” is the second act against AIDS campaign to encourage HIV testing among black MSM. The first, “Know Where You Stand,” was launched earlier this year and targeted black MSM in an ad campaign in 14 cities, as well as on an on-line campaign, to reach black MSM on sites that were frequented by this population. “Testing Makes Us Stronger” will build on that earlier campaign with a new wave of messages, ads and outreach activities. Both of these campaigns were developed with extensive input from an expert panel of 19 experts working in an serving black gay bisexual MSM communities around the country.
Just as black gay and bisexual men are a diverse group, so are efforts to reach them. Elements of “Testing Makes Us Stronger” include a national series of on-line and magazine print ads that are an outlet that will reach black MSM including mainstream African American publications. A few examples of those ads are here in the room, and were distributed by e-mail to those reports joining us by phone. Any reporters who are on the line who didn’t receive that e-mail can call the conference press center at (404) 460-6913, or (404) 460-6914, and we’ll be sure to get you the ads.
Now, the new campaign will also include outreach through social media, including Facebook, Twitter and blogs targeting gay black men. The initial rollout of the campaign will occur in five cities with large numbers of black gay and bisexual men, and high rates of HIV infection. Those first five cities are Atlanta, Houston, New York, Baltimore and Oakland. Promotional materials for distribution and local businesses and community venues in those five cities will be a part of the campaign, as will outreach activities and materials at black pride events that are held around the country, and we’ll also be making available tailored campaign materials for use by local health departments and community organizations throughout the country.
Now I want to take a moment just to quickly acknowledge Mr. Duane Cramer, who is a nationally recognized photographer, who was the photographer for this campaign and is himself an openly gay black man who is also living with HIV, who is a role model for the community and a well-respected leader in the community. “Testing Makes Us Stronger” is scheduled to officially launch on Gay Mens’ HIV/AIDS Awareness Day, which is September 27th, and we’re excited to be able to be a part of that effort.
So now I want to turn it over to Kali Lindsey, of Harlem United, who was a member of the expert panel that worked with us while we were developing and conceptualizing the campaign. Kali, can you share some of your thoughts or some of the process and some of your input into the campaign, and the issues that you felt were most important to be addressed in this and other prevention efforts moving forward?
KALI LINDSEY: Sure, thank you, Dr. Wolitski. I work on structural and systemic issues, like gay men who are at risk for or living with HIV on a daily basis. And for this reason, I welcome the opportunity to work on the “Testing Makes Us Stronger” campaign as an expert panelist. I’m also a black gay man who was diagnosed with HIV in 2003. As a result of that, I have significantly benefitted from learning my HIV status and getting linked to care early on. That’s a benefit that should be afforded to every black gay man who is at risk or living with HIV and is not aware of it today. I also work for an organization that’s on the front lines of providing HIV prevention, treatment and care for people living with HIV and those at risk in New York City, with a specific program that focuses on young black and Latino men at risk or who are living with HIV.
Through those mechanisms, we’re able to recruit individuals from the community and bring them into a comprehensive system of care that can meet their needs early on, and hopefully prevent the spread of HIV. When I became involved with the campaign’s planning process, one of the things that I was most critically concerned with early on is whether or not the campaign would speak to those individuals that weren’t just experienced and have HIV vulnerability and their physical environment, but also in their emotional environment. I wanted to make sure that the messages that were developed, and the creativity that was developed not only talked about how they can avoid risks for HIV, but also how they can live a healthier and better life after knowing their status.
I was thankful to have the privilege of working with 18 other black gay men who work on these issues on a daily basis, and brought their passion, their creativity and their love for the community and love for their fellow brothers to the very hard work that was put into developing this campaign, and I look forward to the implementation process and I look forward to a community mobilized to stop the spread of HIV.
FENTON: Thank you, Kali. Now finally, I’d like to invite Greg Millett, also from the CDC, to hear his thoughts. And Greg, based on the extensive research that you’ve done on this issue, as well as some of the new studies that you’re now looking at or have heard about, would you have any important takeaway – important takeaway thoughts for us this afternoon?
GREG MILLETT: Certainly. Thank you, Dr. Fenton. I’d also like to thank each of my colleagues who presented today. I think that the take-home message for today is that there are a complex range of factors that place black MSM at increased risk for HIV infections. We already know that sexual risk and drug use behavior place individuals at risk for HIV, but the data shown today also highlight how biological and social factors can amplify the risk of HIV infection and in turn magnify racial disparities. Although many research studies have found that black MSM are at increased risk for specific STDs, these studies have been smaller and usually conducted in one clinic or one city. Dr. Su’s ground-breaking use of syphilis surveillance data shows that the phenomenon of greater STD susceptibility among black MSM is a national issue and not confined to a particular locality. As Dr. Su and Dr. Fenton had pointed out, having an STD increases the risk of HIV infection and transmission, and these data partially explain the high rates of HIV infection among black MSM that CDC released last week.
Dr. Kegeles found a high proportion of young black MSM who are unemployed, homeless, or who reported having to borrow money. Another recent CDC study highlighted how HIV infection is associated with poverty in urban areas of the United States. This is because poverty is associated with less access to health care, and people who have HIV and who are not in care are more likely to be infectious than those who are in care. Dr. Kegeles’ data also add to the accumulating research which shows that black MSM are more likely than other MSM to report financial hardship while growing up, and as adults.
Being low income is also associated with other disparities. For instance, a recent study found that young black MSM had poorer nutrition than other young MSM, and poor nutrition may influence immune system functioning and increased susceptibility to HIV or STD. Given these contextual issues, it would be a mistake to blame black MSM for higher HIV and STD rates. In fact, black MSM do more to avoid HIV or STD compared to MSM of other races and ethnicities. Multiple studies have shown that black MSM and particularly young black MSM report fewer sexual partners, less unprotected sex and less drug use than MSM of other races and ethnicities.
However, despite engaging in less risk, black MSM are still more likely to become infected with HIV or an STD. The factors described earlier contribute to a higher proportion of black MSM with HIV or an STD. A greater number of people with HIV or STD in black MSM communities mean that black MSM are more likely to come into contact with someone infected with HIV or an STD compared to MSM in other racial and ethnic communities. This in turn influences higher rates of HIV STD transmission even when black MSM engage in less risk behaviors than other MSM.
- Although stigma towards homosexuality is just as prevalent in black communities as white communities, the consequences of stigma has graver consequences in the black community because a greater number of people are at risk for HIV.
A recent study found that among MSM, twice as many black MSM reported that homosexuality is always wrong, compared with white MSM. MSM with unfavorable attitudes towards homosexuality in that study were also less likely to report ever testing for HIV, compared with MSM who had more favorable attitudes towards homosexuality. This falls in line with Dr. Kegeles’ data showing that sexual risk among young black MSM was associated with higher rates of internalized homophobia and lower affirming perceptions about being gay.
Anti-gay stigma also influences the level of social support MSM receive from their families and communities, which can increase or lower likelihood of risk behavior and HIV infection. A recent CDC study found that black and Latino MSM who reported less social support were more likely to engage in sexual risk behavior and not get tested for HIV compared to young black and Latino MSM who reported higher social support from their families and communities.
We can all respect that people from different belief systems and traditions—come from different belief systems and traditions, but we also have to be mindful that we do not want to inadvertently harm our young people. We have the tools to reduce disparities among black MSM, and as Dr. Wolitski mentioned, CDC has been making these tools available. In addition to existing tools, CDC’s new HIV testing campaign will go a long way in helping to address the disparities in HIV and STD among black MSM through affirming images in messaging. Moreover, the use of social media tools to encourage HIV testing will be more effective in reaching young black MSM among whom rates of HIV infection have increased most, compared to all other groups nationally. As Dr. Fenton mentioned, we can’t allow the health of a new generation of young black MSM to be lost to a preventable disease.
FENTON: Greg, thank you so much for your comments, and I’d like to express my sincere thanks to all of the panelists today for joining us for this very, very important event. Now at this time, we’re very happy to take your questions and we would also encourage your ideas about how we can better help you in your reporting on this topic. It is critically important that we’re able to get this message out in the context that underpins and surround the data that we presented today accurately and clearly and in as compelling a way as possible. So we’d love to hear your thoughts on strategies that could be implemented to help us to get these messages out to engage the communities in new ways, but also to engage the wider population on the realities of HIV AIDS in the United States today.
Now for our reporters and panelists in the room, please be sure to speak into the microphone so that journalists joining us by phone can hear your questions or comments. I’d like to begin by taking a question from the room, if there are any questions or colleagues who would like to ask, please. And could you speak into the mic?
UNIDENTIFIED PARTICIPANT: Sorry. Dr. Fenton, you mentioned that there are non—given the current budgetary situation, there’s not going to be new money probably, and there might even be reductions. You mentioned there are non-monetary things that can be done. Could you mind talking about some of those, particularly changes in the laws, other things that are relatively—either completely cheap or relatively cheap?
FENTON: I think that’s a great question, and I’d also like to invite some of the panelists to respond as well. I think one of the things that we need to think about are the monetary ways in which we can respond to this, which are using the available resources that we have as effectively as possible. And CDC is committed to—through our commitment to high-impact prevention, targeting resources to populations and using those resources to focus on the highest impact activities. But as you’ve heard throughout this meeting so far, it really requires the hearts and minds of all Americans and everyone in the community to both be aware of HIV, to have open and authentic conversations about the epidemic in the United States, as it is today. Not the epidemic of 10 or 15 years ago. To have these conversations with those we love, with our sons and our daughters, especially those of us who have LGBT youth within our families, to begin these conversations, creating supportive and enabling environments for LGBT youth, young gay men, is cost neutral. But it does mean that we need to have honest and open conversations with those we love, and those with whom we have an opportunity to interface with.
A third option, which is non-monetary, is ensuring that the voices of people who are becoming affected and living with this disease are not lost. That is an important role to play in continued advocacy, communication and engagement with those who are leaders within our communities, leaders within our churches, leaders within our schools, and of course for political leaders. And finally, I think that through creating and using opportunities to engage our peers, especially engage facilities in peer to peer engagement among youth, where this concept of resiliency and concept of community responses to this epidemic, can be supported and extended, would be critically important.
Now those are just a few of some of the cost-neutral things that I think that all of us can actually do to get ahead of this epidemic. I wondered if other panelists would like to add to that?
UNIDENTIFIED PARTICIPANT: I’m just going to mention two things, building first some of the remarks that you just made, Dr. Fenton. I mean, I think one thing that’s critically important is the role that parents play. Research has shown that young gay and bisexual children and adolescents who are rejected by their families are at much greater risk for HIV infection and a host of other health threats over their lives. And so an important budget neutral activity that parents and families can undertake is really just to love and support their gay and bisexual children. I think, you know, from a community perspective, one of the things that we’ve made a commitment to with the “Testing Makes Us Stronger” campaign is to make the materials available on line. And so after the campaign is launched, individuals, community-based organizations and health departments around the country will be able to go on line, download posters, Web banners and be a part of the campaign. And so if someone has a blog, they can go download the banner and they can spread this message, they can spread this word. And I think that all of us doing our part to make a difference, that is really what’s going to stop the epidemic.
FENTON: I’m going to ask the—I’m sorry, Kali, did you want to?
LINDSEY: Yes, if you don’t mind. I think the only thing that I will add to that is that when CDC released its updated HIV incidence numbers recently, which indicated that there was a 48 percent increase in HIV infections among young black gay men between 2006 and 2009, the one thing that National Black Gay Men’s Advocacy Coalition highlighted was the more than 50 percent of gay and bisexual men who are not—who do not disclose their same-sex behavior to their providers. That’s a missed opportunity for HIV prevention in our everyday lives. And I’m not only hoping that the “Testing Makes Us Stronger” campaign motivates individuals and empowers individuals to ask for the test themselves, but I’m hoping that these creatives make it into the providers’ offices and into the various areas where people are accessing HIV testing services, and we change provider behavior. Provider education and capacity development is a free mechanism that can really expand access to prevention services in a community, and I hope that this not only mobilizes community black and gay—black, gay and bisexual men, but also HIV or primary care providers that serve black, gay and bisexual men on a daily basis.
FENTON: Thank you. I’m going to pause with the questions in the room just to ask the operator to give instructions to the reporters on the phone to see if there are any questions on the phone that we should be taking now.
OPERATOR: Ladies and gentlemen, if you would like to ask a question on the phone, please press star then one on your touch-tone phone. You will hear a tone indicating you’ve been placed into queue. You may remove yourself from the queue at any time by pressing the pound key. If you’re using a speaker phone, please pick up the handset before dialing and stay on your handset while asking your question.
FENTON: Operator, are there any questions at this time?
OPERATOR: Yes, we have a question from the line of Kai Wright, with colorlines.com. Please go ahead.
KAI WRIGHT: Hi, Dr. Fenton, you mentioned that one of the things—one of the cost-neutral things that we can do is, you know, families having honest conversations about this, and—and—and dealing with homophobia in their families. I’m wondering, is there a way so that – you know, communication is easier said than done in many families, and is there a way that either the CDC or local health departments can be supporting that kind of conversation? What can—what can health officials do to support parents who are trying to do that, but don’t know how?
FENTON: I’m going to ask Dr. Wolitski to respond to that question, and I will also add a few thoughts from other parts of work that’s being done in CDC at the moment.
WOLITSKI: There’s actually a great Web site and toolkit that’s been developed for families that summarize some of the research that’s been done in this area, and that give parents some tips as to how they can talk with their kids about these issues and how they can be supportive and that’s something that—I don’t have that information with me at this exact moment, but that’s something that we’d be happy to follow up with you and others to make available to you.
FENTON: Dr. Kegeles?
KEGELES: I’ve conducted some other research with faith-based organizations—African American faith-based organizations. And what I’ve found was that although the faith-based organizations, many of them would have a very difficult time talking about sex, they’re eager to talk—many of them are eager to talk about testing. And some of the men, sometimes young gay and bisexual men, particularly in the South, are involved with faith-based organizations, but regardless of where you’re talking about in the U.S., the mothers and the grandmothers are there. And so I thought it would be a wonderful opportunity to get the grandmothers and the mothers talking with their gay sons about the importance of testing. They don’t have to talk about sex, they can just be neutral about that, but they can talk about the importance of finding out if you have HIV and getting on to treatment.
FENTON: Great, thank you. And my final comment to your question, and thank you so much for the question, is our CDC division of adolescent and school health also produces resources to help both youth within school, to help schools themselves, to build capacity around sexual health education and awareness for youth, but also to provide tools for families and parents to have some of these conversations with their children as well, or with young adults as well as far as promoting HIV awareness, STD awareness, and promoting sexual health. And again, we’d encourage you to visit the CDC Web site to have access to some of those tools that are available for engaging youth where they’re likely to live, work and play.
We’ll take another question in the room.
DAVID MUNAR: Thanks, Dr. Fenton and panel. I’m David Munar, and I’m blogging and also submitting for the Windy City Times. You—all your presentations underscored the role of homophobia and internalized homophobia as a driver for HIV risk. I wanted to ask if you would—and actually, Dr. Fenton, you opened up the presentation by underscoring the need for policy and laws to help this group. I was wondering if you could elaborate more about what are some of those structural, policy and legal changes that might help alleviate some of the homophobia or internalized homophobia, that might be supported either locally or by states or by federal government or federal officials? And I would observe that the campaign that’s rolling out, “Testing Makes Us Stronger,” has a strong focus on acceptance of testing, but doesn’t actually address the homophobia. And Assistant Secretary for Public Affairs Richard Sorian this morning in “The Plenary” actually said that the campaign ought to be calibrated for behaviors beyond HIV testing acceptance. I’m wondering if you could also respond to that.
FENTON: Great. So thank you so much for that question. So I’ll begin by just providing a little bit of context, and one of the contexts is that homophobia does not exist on its own. It occurs within a culture which is going to be enabling. And I think parts of strategies that are going to be geared towards addressing this issue need to think—or need to address some of the societal level contexts which are occurring that allows homophobia to thrive within any given society. So as you think about some of the interventions, I think we should also reflect on some of the huge changes that we’ve seen in very recent times, in the ways in which LGBT issues and issues related to the lives and well-being of LGBT people in the United States, has changed tremendously. Whether it’s the repeal of don’t ask don’t tell, or whether it is the commitment of this administration to look at systematic ways in which LGBT individuals in this country are discriminated against and to address these systematically, these are ways in which the context is in fact changing.
As far as homophobia is concerned, I’d like to perhaps turn to some of the researchers on the panel to see if there’s anything from the literature that could help us to think about evidence-based approaches to addressing homophobia, either in the United States or in the world, that perhaps colleagues would like to raise today.
KEGELES: Well, this is more about internalized homophobia, but I have developed a program called empowerment, and in this program, young men talk about how they feel about being gay or bisexual, and so they share their feelings, they talk about the difficulties they have with their family, and they really get into issues about pride, how to feel good about who they are. They learn about gay heroes, black gay heroes, and they learn to critically analyze the kind of messages that they’ve heard and decide whether or not they’re going to refute those messages. And of course our push is that they do refute the homonegative messages that they’ve heard and instead gain pride about who they are.
So in this way, we try to help them to cope with those kinds of things that are happening in the external world so that they don’t hurt as badly and they can deal with them and not internalize them as deeply.
FENTON: Great, OK.
UNIDENTIFIED PARTICIPANT: I’d like to amplify the point that Dr. Fenton had made about the context of homophobia. I do believe there are several things that are really important about this new campaign that CDC is launching. One of them is the fact that it’s a campaign that shows positive images of healthy black MSM, who are affectionate with one another, who are living their lives openly, in a way that is—that really hasn’t been done at a national level in the past. And that virtual invisibility of black MSM and images for black MSM has certainly contributed to some of the issues that we’ve been discussing earlier today.
I also think that the fact that this campaign is not only going to be placed in black MSM journals and publications, or even gay journals and publications, but will also be placed in mainstream publications and particularly publications for the African-American community overall, goes a long way in addressing stigma and homophobia in the African American community, as well as showing images of black MSM within the community.
So I really think that this campaign is a huge step forward, and something that’s extremely exciting, that can really address a lot of the issues that we’ve been discussing today
FENTON: Great, thank you. I’m going to return to the phone. Operator, are there any other questions on the phone?
OPERATOR: Yes, we have a question from the line of Dyana Bagby, with Georgia Voice newspaper. Please go ahead.
DYANA BAGBY: Hi, thanks for taking my call. I—the 48 percent increase that has been shown with young black MSMs from 2006 to 2009, was that caused—I mean, was that number reached through more testing? I’ve talked to several people who say these numbers really aren’t new, but can you address our—how these numbers have risen so much, and if increased testing played a role in that?
FENTON: I’m going to see if Dr. Wolitski would like to respond? Begin the response?
WOLITSKI: Yes, so we do not believe that these data represent an increase in HIV testing among black men who have sex with men. Rather, we believe that they represent an increase in new HIV infections within this population. Now, the methods that are used to calculate this incidence estimate are susceptible to variations in the frequency of HIV testing, and that is a potential influence that could affect the precision of the estimate, but the best available data that we currently have suggests that this represents an increase in new HIV infections rather than an increase in HIV testing.
FENTON: Is there a follow-up to that question?
BAGBY: But, this demographic had high rates since ’98, I believe. And still, you know, it seems to rise and I don’t know if there’s—and I know you’ve tried to touch on how and why and what people can do to stop it, and I guess there isn’t really a follow-up question, it just seems like a frustrating issue.
FENTON: And we share your frustration, and I think this is exactly the reason why we’re focusing on this topic this afternoon. And just to summarize what I’d like us to begin taking away from this session is that this is a complex issue. It is a multi-layered issue. It involves thinking about risk behaviors, it involves thinking about partnerships, sexual networks that men are in, the community and societal response, and therefore any response that we will have to put in place for this trend that we’re seeing epidemiologically has to be comprehensive, it has to be sustained, it has to engage the community and it has to ensure that we’re addressing many of the drivers for HIV incidence in this group.
So I share that sense of frustration that you have, and that’s exactly the reason we’re having this conversation today. And your thoughts on ways in which we can continue to communicate this to our partners and to the community would be incredibly invaluable.
WOLITSKI: And I was just going to, you know, add, I think one of the things that is important to keep in mind is that many young black men who have sex with men haven’t necessarily seen themselves represented in other HIV prevention efforts and other campaigns in the past, and that’s why it’s critically important that we have a campaign like “Testing Makes Us Stronger” that is representing the diversity of the black gay bisexual MSM community and is clearly communicating the impact and the risks that this disease is having specifically on this community.
FENTON: OK, we have a couple of questions in the room, so I’m going to take questions in the room, and then we’ll be closing off shortly.
LISA DESAI: My name’s Lisa Desai, I’m working on a documentary for PBS about HIV in the rural south. I understand that the five cities you chose, I believe, were because of sheer numbers, I’m not sure. But I’m curious about how these kind of campaigns will trickle down into rural areas, where the epidemic is on the rise. And I’m working with families that don’t have, you know, Internet access or pastors that will talk. So how will this help those kind of communities.
FENTON: OK, Dr. Wolitski, would you like to start the response to that in terms of—
WOLITSKI: So I think, I mean one of the ways that CDC is able to be effective is through our partnerships with local health departments and local community organizations that are working in rural areas as well as small, medium and large cities. And so making these materials available to these communities is certainly going to be one part of that strategy. And engaging these communities in talking about how this campaign and other intervention activities can be used in their community. I mean, the intervention that Dr. Kegeles has been working on for a couple of decades now, at least, the empowerment project, is really a grass roots intervention where young men come together and they themselves effect the change in their community, and that intervention has been used successfully in rural settings, and in settings with small communities as well. So I think there are—you know, we have a growing number of tools that work not only in large urban areas, but we’re increasingly seeing that they can be adapted and be effective in small communities as well.
FENTON: So partnerships are going to be key.
GREG MILLETT: I’d also like to add just one quick point, is that we also need to make sure that people realize that being in a rural setting and being in an urban setting are not necessarily mutually exclusive, especially for MSM populations. There’s a lot of back and forth, where MSM travel to larger urban centers for major gatherings, for parties, for various things that are taking place, and that there are opportunities in those urban settings not only for risk, but certainly opportunities for disseminating some of the information, like the national campaign that we’re disseminating today, to reach those MSM. So there’s definitely opportunities to reach MSM who are from rural communities, who are traveling to national urban centers, who will also have opportunities to be able to be reached by this campaign.
FENTON: Great. We’ll take one final question from the room.
BOB ROEHR: Bob Roehr, Bay Area Reporter. Several weeks ago, there was an institute of medicine report on women’s health prevention issues, and HHS subsequently adopted that in guidelines which require health insurers to provide, free of cost, a certain package of health prevention interventions that includes HIV and STDs, as some of the major focuses. What came up yesterday, in one of the satellite sessions that for men, one of the equivalent components of that is access to circumcision. But health care often doesn’t cover that, and most state Medicaid programs which disproportionately serve, you know, people of color, lower income people in general, but people of color in particular, and therefore they don’t have health access to this. What can be done to make sure that this package of basic health prevention services that have to be offered to everyone as part of all of their coverage, to make sure that is included as an option for people?
FENTON: Do you want to—so thank you for the question. I’m going to give you a brief response, and I’d be happy to follow this up off line. I think you raised an important point, and I’d like to begin by saying, first of all, we were delighted with the IRM’s report and HHS’s very subsequent and very quick action to move definitively on accepting the recommendations for women’s health.
I think your second point about what are the equivalent interventions that should be in the prevention packet for men’s health is critically important, and that work needs to be done to identify which are the most effective and cost-effective interventions that should be packaged, whether it’s circumcision, HIV testing, screening for STDs, et cetera.
CDC’s part is to release our recommendations on circumcision later this year, and that will provide an opportunity for a wider discussion on the benefits of adult male circumcision and ways in which, as a country, we need to be moving forward and thinking about our strategies of circumcision in the U.S. both taking into consideration the benefits as well as the potential costs of circumcision. And I think once those recommendations are out and we have public as well as partner engagement on these recommendations and a clear vision for moving forward, we can begin to incorporate ways in which we should build that into the prevention package for men’s health. So thank you for that.
This brings us to the end of this session. If you need further information, or if you’d like a transcript, I’m going to ask you please to call our staff in the conference press room. That number is (404) 460-6913, or (404) 460-6914. Thank you all for joining us this afternoon.
OPERATOR: This call—ladies and gentlemen, this concludes our conference call for today. As a reminder, this call has been recorded and it will be available for replay beginning at 3 p.m. Eastern Daylight Time today, and available through 11:59 p.m. Eastern Daylight Time on August the 22nd. You may access the recording by dialing 1-800-475-6701 from the United States, or international callers may dial (320) 365-3844 and enter the access code 213104. Once again, thank you for your participation. You may now disconnect.
CONFERENCE CALL ON AUG. 16, 2011
Tuesday, August 16 at 12:30 p.m. ET
WHO: Jonathan Mermin, M.D., M.P.H., Director, Division of HIV/AIDS Prevention (DHAP), CDC
Alexandra Oster, M.D., Medical Epidemiologist, DHAP, CDC
? Presenting results of a 21-city analysis examining HIV testing and risk behavior among MSM, injection drug users, and heterosexuals with low socioeconomic status
Natalie Cramer, M.S.W., Associate Director of Prevention, National Alliance of State and Territorial AIDS Directors (NASTAD)
? Presenting results of a national survey of health department efforts to implement CDC’s routine HIV testing recommendations
Ann Avery, M.D., Medical Director, Cleveland Department of Public Health
? Presenting results from a study of a system-wide change at a large hospital system in Cleveland designed to increase integration of HIV testing into routine care
Irene Hall, Ph.D., M.P.H., Chief, HIV Incidence and Case Surveillance Branch, DHAP, CDC
? Presenting results of a multi-state analysis examining retention in care of HIV-infected individuals
Jennifer Sayles, M.D., M.P.H., Medical Director, Office of AIDS Programs and Policy, Los Angeles County Department of Public Health
? Presenting results of two studies assessing innovative use of mapping technologies in Los Angeles County to improve targeting and integration of HIV and STD treatment and prevention services
NHAS Media Briefing
August 16, 2011
12:30 p.m. EST
JONATHAN MERMIN: Great. Good afternoon, everybody. I’m Dr. Jonathan Mermin, and I’m the director of CDC’s Division of HIV/AIDS Prevention. Thank you all for joining us, including the journalists in the room and participating on the phone. With the start of this briefing, all embargoes for the research that will now be discussed are now lifted, and summaries of all the studies that will be highlighted in the briefing are included in your press kits. If you didn’t receive the materials, please see one of our media representatives after the press briefing, or call the press room at (404) 460-6913, or (404) 460-6914.
So in the briefing, we’ll focus on research related to the priorities of the National HIV/AIDS strategy, which was released by the president about a year ago. The strategy calls on federal, state and private partners to reduce new HIV infections, address disparities and prevention in care, and improve health outcomes for people living with HIV. The studies we’ll be highlighting today touch on all three of these critical areas. So I’d like to take a brief moment to introduce our panel. I’m joined today by some distinguished scientists and clinicians. On my left is Dr. Alexandra Oster, the medical epidemiologist at CDC, Natalie Cramer, an associate director of prevention at the National Alliance of State and Territorial AIDS Directors, or NASTAD, Dr. Ann Avery, the medical director for the Cleveland Department of Public Health and an infectious disease physician at the Metro Health Medical Center, Dr. Irene Hall, the chief of the HIV incidence and case surveillance branch at CDC, and Dr. Jennifer Sayles, medical director of the office of AIDS programs and policy at the Los Angeles County department of public health.
We’ll hear from each of them in a moment, but before I turn over the podium, I’d like to provide some brief background about the current state of the U.S. HIV epidemic. About two weeks ago, CDC released new estimates of the annual number of new HIV infections in the U.S. from 2006 to 2009. The new data show that the number of new HIV infections in the country has been relatively stable over that four-year period, with approximately 50,000 people infected with HIV each year. While it’s good news that HIV prevention efforts have helped avert increases in HIV infections overall, a stable number of new HIV infections at this high of a level is neither acceptable nor sustainable. The estimates also show an alarming 48 percent increase among black men who have sex with men aged 13 to 29 years, and this is the only specific sub-population in the U.S. to experience a sustained statistically significant increase during this period.
We’re troubled by this trend. It points to an urgent need for action at every level to ensure the health of a new generation of young men is not lost to a preventable disease. Three of the studies we’ll be highlighting today relate to HIV testing, which is a key part of the national HIV/AIDS strategy and CDC’s prevention efforts. The strategy calls for increasing the percentage of HIV positive people who know they have the virus to 90 percent by 2015, from 80 percent today. This is critical, since the majority of new HIV infections in the U.S. occur because people who do not know they have the virus unknowingly transmit it to others.
What happens after a person gets tested for HIV can be just as critical as taking the test in the first place. A negative test provides an opportunity to link high-risk individuals to needed prevention services to help them stay negative. And HIV testing allows individuals who discover they are infected to be connected to ongoing treatment, care and prevention services. Anti-retroviral treatment not only helps people with HIV live longer, healthier lives, it also has important implications for prevention. A large study published last month showed that early treatment of HIV-infected people can dramatically reduce their chances of transmitting HIV to others by an estimated 96 percent.
The national HIV/AIDS strategy includes specific goals for increasing the percentage of HIV positive patients retained in care, as well as increasing the proportion of them who are being successfully treated for HIV. In this briefing, we’ll be highlighting analyses that relate to both of these goals. Thanks to recent breakthroughs in HIV prevention, we now have even more tools to bring an end to the U.S. HIV epidemic, but we need to find the most effective ways to reach those at risk with the right combination of approaches, and we must do this in an environment where research challenges are significant, not only for governments but also for all individuals throughout the United States.
To get the maximum benefit from the resources we have available, CDC is pursuing an approach we call high-impact prevention. Through high-impact prevention, we are directing funds to support the most effective combinations of prevention interventions, targeted to the highest risk populations for transmission or acquisition in the right geographic areas, and that are practical to implement on a significant scale at a reasonable cost. One major example of this new approach is CDC’s recent state level prevention funding announcement. Our new approach does a better job of targeting resources to the geographic burden of the HIV epidemic today.
We also ensure in that funding announcement that resources will be covering all of the populations affected by HIV, women and men, gay men and straight men, injection drug users—everyone who is potentially affected by HIV or infected with HIV will be reached through this funding announcement. The overhaul directs health departments to use the resources for the prevention activities that will have the most significant and lasting impact, and to ensure that prevention efforts are directed to the populations that need them most in their local area.
So I’d now like to call upon Dr. Oster, who will briefly summarize the key findings from a 21-city analysis on HIV testing and risk behaviors among three groups at high risk for HIV. Dr. Oster.
ALEXANDRA OSTER: Thank you, Dr. Mermin. CDC’s National HIV Behavioral Surveillance System, or NHBS, was developed to provide data on the groups at high risk for HIV infection in the United States. We examined a large, 21-city sample of men who report sex with other men, or MSM, and individuals who report injection drug use, IDU, both defined as individuals having engaged in those behaviors within the past 12 months. We’ve also worked to identify and examine a large sample of heterosexuals at increased risk for HIV in the same cities. Because our pilot studies determine that measures of socioeconomic status were more effective at identifying heterosexuals at risk for HIV than individual level factors, the heterosexual sample is defined based on those criteria. Specifically, we examined low SES heterosexuals, defined as heterosexuals with an income at or below the federal poverty level, or who have an education level not greater than high school.
It’s important to understand that NHBS data are not nationally representative. Rather, they provide a snapshot of the epidemic among three groups at very high risk for HIV. The information is important because it provides insight into the population we most need to be reaching with effective prevention services. This latest NHBS analysis includes data from about 30,000 individuals living in 21 major U.S. cities, roughly 10,000 people from each of the three risk groups. Among the three groups studied, the latest data show substantial levels of HIV infection and high rates of risk behavior, along with infrequent HIV testing and low awareness of infection among those living with HIV.
Specifically, with respect to HIV prevalence, 19 percent of MSM, nine percent of IDUs and two percent of low SES heterosexuals were infected with HIV. By comparison, the level of infection in the overall U.S. population is less than ½ of one percent. And among those infected, nearly half in each of the three risk groups were unaware of their infection. This is a major concern since, as Dr. Mermin mentioned, CDC estimates that the majority of new HIV infections in the U.S. are transmitted by people who do not know they have the virus. CDC recommends that all adolescents and adults be tested for HIV as a standard part of routine medical care, and that individuals at high risk get tested at least annually. However, our analysis finds relatively low proportions of individuals in these high risk groups have been tested in the previous 12 months, 62 percent of MSM, 49 percent of IDUs and 33 percent of low SES heterosexuals.
The analysis also found high levels of risk behavior in the previous 12 months. Among MSM, 54 percent reported engaging in unprotected anal intercourse with a male partner. Among IDUs, 36 percent reported sharing syringes, 58 percent reported sharing other injection equipment, and 71 percent reported unprotected vaginal intercourse with an opposite sex partner. And among sexually active low SES heterosexuals, 89 percent reported unprotected vaginal intercourse.
Finally, despite high levels of risk behavior, the analysis shows that few had accessed behavior change programs proven to reduce HIV risk. Specifically, only 18 percent of MSM, 21 percent of IDUs and 11 percent of low SES heterosexuals reported participating in an individual or group level intervention in the prior year. We are currently conducting additional analyses that will provide data by gender, age, race ethnicity and other variables for IDUs and low SES heterosexuals, which will be published over the next year. For MSM, some of those breakdowns have already been published in CDC’s MMWR, though additional analyses are underway to further examine MSM risk behavior and HIV testing patterns.
MERMIN: Thank you very much, Dr. Oster. These data underscore the urgency of increasing the impact of our prevention efforts, especially for those at highest risk for infection. The latest NHBS data also reinforce the importance of HIV testing. We need to prioritize reaching the 240,000 individuals in the U.S. who are unaware that they have HIV, so that they can be connected to treatment and care that they need for their own health, and to help prevent transmission to others. At this time, I’d like to call upon Ms. Natalie Cramer to highlight the results of a national survey that NASTAD conducted examining health department efforts to implement CDC’s routine HIV testing recommendations.
NATALIE CRAMER: Thank you, Dr. Mermin. NASTAD is a membership organization that represents the state and territorial health departments around HIV and viral hepatitis programs. And in that capacity, we provide technical assistance and advocacy, and to inform those efforts, we conduct a number of surveys on our membership. This survey, conducted in February of 2010 under the direction of NASTAD consultant Lisa Randall, is a follow-up survey to one conducted in 2007, which assessed overall levels of testing in health care settings. The 2010 survey is the first to specifically assess health departments’ efforts to implement routine HIV testing. And by that, I mean testing of all patients without regard to clinical symptoms or behavioral risk, so comparisons to earlier years on this specific measure are not possible.
Seventy-five percent of health departments reported providing support for routine HIV testing in a variety of health care settings. The most common venues were STD clinics, hospital emergency departments and community health clinics. A majority also reported supporting routine testing in substance abuse treatment centers, correctional facilities and family planning clinics. Our analyses found that 59 percent of health departments planned to expand routine HIV testing activities in the next year, citing hospital emergency departments and community health clinics as top priorities.
Our survey also examined the legal, regulatory and policy environments within states as they relate to the implementation of CDC’s routine HIV testing recommendations, and found them to be increasingly favorable compared to the 2007 survey results. For example, CDC recommends that consent for HIV testing be incorporated into general consent to medical care, to streamline the process, rather than requiring separate written informed consent. Our survey found that the number of states requiring special written consent decreased by 50 percent to 17 states in 2010, compared with 34 in 2007. Also, CDC advises that pre-test counseling no longer be required, because time-intensive counseling can serve as a barrier to testing in busy medical settings. Fewer states legally require pre-test counseling, 14 in 2010 compared with 21 in 2007.
Despite this progress, the analysis highlights several remaining challenges. We asked health departments to rank the top barriers in implementing routine HIV testing in health care settings. Lack of adequate funding was ranked as the top barrier, as it was in 2007. This was followed by health care provider resistance, and we dug a bit deeper and found that health departments reported they believed competing priorities and not wanting to disrupt work flow were the main reasons providers did not want to implement routine testing.
A majority of health departments also cited the lack of reimbursement for HIV testing as a significant challenge to expanding routine HIV testing. At the time of this survey, about ¼ of health departments reported that their state Medicaid programs do not provide reimbursement for routine HIV testing. As Dr. Mermin said, increasing implementation of routine HIV testing is critical to achieving the goals of the national HIV and AIDS strategy, which calls for reducing new infections by 25 percent by 2015. CDC estimates that one in five people living with HIV in the United States are unaware of their status. Expanding HIV testing efforts to identify these individuals is essential, since the majority of new infections in the United States occur because people who do not know they’re infected unknowingly transmit the virus to others.
NASTAD’s analysis underscores the critical role that health departments can play in implementing and increasing routine HIV testing.
MERMIN: Thank you very much, Natalie. The survey underscores the critical role that health departments continue to play in expanding the implementation of routine HIV testing, as well as targeted testing, and it’s encouraging to see such significant progress in a relatively short period of time. I’d now like to turn things over to Dr. Ann Avery, who will tell us about a relatively simple change that was made to clinical procedures in a large hospital in Cleveland, which has had a major impact on increasing uptake of routine HIV testing there.
ANN AVERY: Thank you, Dr. Mermin. So we took advantage of the fact that our health care system has had a comprehensive electronic medical records since 1999. Our health care system includes a large hospital with a rehab—rehabilitation and trauma center, as well as 11 affiliated community health centers. All are connected on this electronic medical record. We utilized the system to be able to provide an in-depth evaluation on an encounter basis of HIV testing based on the current CDC guidelines that everyone be tested at least once between the ages of 13 and 64. We began the project in 2009, and also compared it with education to providers around the guidelines around routine testing. We took a look at 2008 and 2009 primary care encounters occurring in five of the community health centers that are located in the highest prevalence of HIV in our community, as well as the primary care clinics at the hospital, and then the inpatient units. So we looked at a lot of patients. We—our numbers are about 186,000 in each year of encounter data.
In this initial analysis, we found that the majority of men had never been tested, despite having encounters, and that included from 1999 until the date of that encounter. So 80 percent of men had missed opportunities for testing. The women fared a little bit better, with the women of child-bearing age having more than 50 percent having been tested, but older women not having been tested. We utilized this information in education to providers, and also to leverage the administrative power to actually change our health maintenance list. This is a list that the providers use for an outpatient setting to remind them of preventative health care screenings. So in July of 2010, we had the ability to actually update our health maintenance list to include HIV testing once for anybody that was 13 to 64, seeking medical treatment in the system. This list is something that, as I said, the providers were already using to remind themselves of preventative health maintenance, and is also used to monitor quality markers. HIV testing was not included as a quality marker.
About the week after this implementation went live, testing doubled, which was fabulous. We also updated our educational component to focus on some of the barriers that Ms. Cramer commented that were cited, like barriers about communication and fear of talking. So our educational components around testing was limited to a 15 minute didactic, and then three case series that focused on communication skills for providers. We looked at the pre-intervention testing and then post-intervention testing, and ¾ after the intervention was implemented, so as of the end of March of 2011, testing has continued to increase at a significant basis of those among—those getting first-time tested. So we have dramatically decreased missed opportunities for men of all ages, and women especially in the older age groups 40 and over, although all women have also benefited. And we see this as both a cost-effective and fairly simple structural intervention that helped normalize testing for the providers and decreased that barrier to getting individuals tested, and we believe that in settings where an electronic medical records system is in place, this may be a helpful structural intervention to achieve the national HIV/AIDS strategy of getting everyone to actually know their status. Thank you.
MERMIN: Thank you, Dr. Avery. Those are impressive results, and I hope that the changes that have been able to be made in Cleveland serve as an inspiration and a model to other health care systems. Next, I’d like to invite Dr. Irene Hall to share with us the results of a multi-state analysis examining the proportion of people living with HIV who are retained in care.
IRENE HALL: Thank you, Dr. Mermin. My colleagues and I conducted an analysis of more than 100,000 HIV-infected people in 13 areas in the U.S. that have mandatory laboratory reporting of HIV-related tests. We did this to assess the proportion that was retained in care, which we defined as having at least one CD4 or viral load test in the previous year. CD4 and viral load tests provide essential information that the health providers need to evaluate progression of disease, guide treatment decisions, and generally monitor the patient’s overall condition. We found that 59 percent of HIV infected individuals in those areas were in care, which indicates that a significant proportion, that is 41 percent, were not receiving the care they need to keep themselves healthy and to help reduce their chances of transmitting HIV to others.
We identified significant racial and ethnic disparities in the number of people receiving these tests. While 64 percent of HIV-infected whites had received a CD4 viral load test at least once in 2009, only 55 percent of African Americans and 49 percent of Latinos had received one of the tests. These disparities in care mirror the overall disparities and the impact of HIV in the U.S. in which racial ethnic minorities experience far higher levels of new HIV infections, AIDS diagnoses and deaths.
I would like to note that the definition of retention in care that we used in the study is much less stringent than current federal guidelines, which call for HIV infected individuals to be tested for CD4 and viral load every three to four months, unless the virus is considered suppressed, in which case it is recommended that they are tested every six to 12 months.
Similarly, the national HIV/AIDS strategy defines continuous care as receiving these tests at least twice in the previous year, with at least three months’ interval between the tests. By the national strategy standards, less than half of HIV infected people in the study —45 percent—would have been considered retained in care. Retaining people in care not only benefits those living with HIV, but also plays an important role in preventing the spread of the virus. HIV infected individuals in care are able to receive HIV counseling and prevention services that can help them maintain safe behaviors to protect their sexual and needle-sharing partners from infection over the long term.
In addition, HIV care is the gateway to treatment, which can both slow progression of HIV disease and dramatically lower the risk of transmission to others by reducing the amount of virus in the blood.
MERMIN: Thank you, Dr. Hall. This analysis reinforces the importance of targeted efforts to increase retention in care for all people with HIV, including those who currently don’t have as high a proportion as others, such as African Americans and Latinos. As I mentioned earlier in the briefing, closing gaps in HIV care and reducing racial and ethnic disparities are critical to advancing the national HIV/AIDS strategy. This strategy includes specific goals for increasing the proportion of Ryan White patients who are in continuous care. The federal Ryan White Care Act supports HIV infected individuals who have low incomes or are uninsured or underinsured. The strategy also calls for increasing the percentage of African Americans, Latinos and men who have sex with men who are being treated successfully, that is who have a very low or undetectable level of virus in their blood.
Our next speaker is quite familiar with those particular aspects of this strategy, and I’d like to call upon Dr. Jennifer Sayles to tell us about the innovative ways that Los Angeles County is using mapping technologies to assess treatment coverage of its Ryan White patients, determine the proportion of them who have undetectable viral loads, and identify the factors associated with not having undetectable viral loads so that we can do something about them. Dr. Sayles will also highlight how these mapping technologies are helping them target and integrate HIV and sexually transmitted disease prevention services.
JENNIFER SAYLES: Thank you—excuse me, thank you, Dr. Mermin. So I’ll describe two studies that we conducted using existing public health department data to better target HIV prevention efforts where they will have the greatest impact which, as you mentioned, is a key step for L.A. County to align itself with the national HIV/AIDS strategy goals.
With almost 10 million residents, Los Angeles County is the most populous county in the nation. Because disease load is not evenly distributed, we need to identify the particular populations and communities most in need of prevention services. In light of the emerging evidence for HIV treatment as prevention, our first study examined treatment coverage rates and predictors of detectable viral load in the L.A. County Ryan White system of care. In this analysis, we looked at a sample of approximately 12,000 HIV positive individuals who were receiving medical care in the Ryan White system in 2009. We found that the overall treatment coverage rates were very high, 90 percent of patients were receiving anti-retroviral therapy. We also found that of those on treatment, on average over a quarter, or 27 percent, still had detectable viral load and were not achieving the full viral suppression to be expected from medications.
We then looked at geographic variations in treatment coverage and HIV viral load levels in the sample. We found that the overall mean viral load, which is calculated by summing up the most recent viral load for each person in the Ryan White system and dividing by the total number, was 16,807 copies, 72 percent of people in the system had an undetectable viral load. There was also significant geographic variation such as the same areas of the county that had lower coverage rates also had higher mean viral loads and a lower proportion of individuals achieving viral load suppression went on therapy.
Next, we developed a model to identify factors that were associated with having a detectable viral load, which we defined as more than 200 copies in the sample. Given viral load is the strongest predictor of HIV transmission, identifying those populations or groups that may have higher rates of having detectable viral loads is an important step in determining how to target prevention services to reduce forward HIV transmission. In our model, we found that women had slightly increased odds compared to men of having a detectable viral load. African Americans had 1.42 times the odds of having a detectable viral load compared to whites, whereas Latinos and Asian Pacific Islanders had lower odds. Compared to those over 50, use under age 24 had over three times the odds of having a detectable viral load. Additionally, those living below 100 percent of federal poverty level, those with recent substance abuse, and those who had recently been incarcerated also had increased odds of having a detectable viral load.
In conclusion, this analysis provides important information to inform strategies to utilize treatment as a prevention tool for L.A. Our data suggests that interventions to address access and adherence to anti-retroviral therapy among the use—African-Americans, substance users and recently incarcerated populations are urgently needed. And finally, the geographic distribution of viral load will be used to further target HIV prevention and testing programs as part of a coordinated and enhanced jurisdictional response.
Our second study, which was titled “a syndemic spatial analysis of HIV and STD disease burden” is focused on geographically targeting prevention services to increase their impact. This analysis used spatial statistical methods and HIV and STD surveillance data to identify specific geographic areas in the county that accounted for the majority of new HIV, syphilis and gonorrhea cases. The analysis was conducted as a part of a grant for the enhanced comprehensive HIV prevention planning, a CDC-funded demonstration project in 12 U.S. cities to develop strategies that will increase the impact of HIV prevention efforts. Our team notes all reported cases of HIV, syphilis and gonorrhea in the county. We discovered that each of the three diseases was clustered geographically at a statistically significant level. To do this, we used what’s called nearest neighbor hierarchical clustering, which looks for statistical evidence of geospatial clustering of cases, or groupings of infections. We were able to identify the five most highly impacted areas where the HIV, syphilis and gonorrhea clusters overlapped. These hot spots represented approximately 80 percent of cases reported in 2009, but were concentrated in less than a third of the county’s total overall geographic area.
Additionally, high rates of poverty were found to correlate with the cluster areas containing the highest number of new HIV and STD cases. We also found that 74 percent of publicly-funded HIV testing programs fall within these cluster areas. Because STDs are often co-factors in HIV transmission, identifying the most highly impacted areas across these syndemics will help us to better target prevention services to those most in need. For example, we are currently using this model to direct where we will expand our routine HIV testing efforts. Integrating HIV and STD prevention also enables the county to take a more comprehensive and coordinated approach to disease prevention, another goal of the national HIV/AIDS strategy.
MERMIN: Thank you, Dr. Sayles. The work you and your colleagues are doing in Los Angeles County is helping to ensure that care and prevention efforts reach everyone who needs them, and are having the greatest possible impact. At its core, that’s what all of us working in HIV, national strategy and CDC’s high impact prevention are trying to do.
At this time, I’d be happy to take questions. Please be sure to speak into the microphone so journalists joining us by phone can hear your questions, and let me take a question from the room first, but like also to take a brief pause so the operator may give instructions to reporters on the phone, so that they may also ask questions
OPERATOR: Thank you. And ladies and gentlemen, if you would like to ask a question, please press star and then one on your touchtone phone. You’ll hear a tone indicating you’ve been placed in queue, and you can remove yourself from queue at any time by pressing the pound key. If you’re using a speaker phone, please pick up the handset before dialing, and stay on your handset while asking your question. And once again, it’s star and then one.
BOB ROEHR: Thank you, Bob Roehr, Bay Area Reporter. Right now, acute infection is modeled to be a very important point of transmission—of ongoing transmission of new infections. And as all of these other efforts are put into effect, it probably is going to stay a relatively large portion, maybe even grow as the pie shrinks. What is being done now to try and educate providers and patients to be able to better identify acute infection and react in a timely way to reduce ongoing transmission?
MERMIN: Thank you for that question. I think there are two issues that come up with your question. The first is, how can we diagnose effectively acute HIV infection itself, and are there new technologies or new approaches that might assist us in that manner? And the other is, what do we do with that information to make sure that people with acute infection are provided both the prevention services but also perhaps the treatment that may help them? And I’m going to turn to Dr. Hall to answer some of these questions.
HALL: So, as far as the diagnosis is concerned, we have new tests that may be able to get at that with the new testing algorithm that will be released later this year. So when that happens, then that’s the first step in identifying the people with acute infection. I can’t speak to really what the—what the provider side would be to that, so I might probably have to turn that over to—
MERMIN: Maybe Dr. Avery.
ROEHR: One clarification though in your new algorithms and the testing there. How soon after exposure does one do those, identify a patient who has been infected? Because in some instances, it can be, you know, a matter of days or weeks, at the very most, is important for potentially—for intervening for therapy, and certainly for stopping onward transmission.
HALL: That’s correct, so the—what’s called the window period, the time period between, you know, really exposure and when the virus can be detected, is getting very small and it’s less than a week, I think, at this point.
MERMIN: Yes, just to clarify. So the new fourth generation HIV test includes both a way of detecting antigen, which is the virus itself, and antibody, which is a product of the immune system in response to infection. Traditionally, we’ve used the antibody test ways—and there’s a delay time for your body to produce antibodies. Because this new technology is able to detect antigen, it is able to detect people who have infection but haven’t yet produced enough antibody to be positive. The traditional way we’ve diagnosed those individuals is with nucleic acid testing. We actually detect the RNA of the virus itself. These tests are almost as good—they’re within five days on average of the time period when the nucleic acid testing itself would detect them. So really it is pushing the envelope towards almost the—the—the accuracy of some of these more expensive and more difficult to conduct nucleic acid testing.
They are not available in rapid testing form at the current time in the United States, but that’s probably technology that will be coming down—or becoming available soon.
Maybe Dr. Sayles would also like to clarify?
SAYLES: I was just going to say, I can actually speak a little bit to what we’re doing in Los Angeles County specifically to try and identify acute infection, and I think our approach has been, in very high-risk populations, we have an algorithm whereby there’s—since there’s no rapid test fourth generation available, we use third generation rapid testing and then, for anyone who tests negative who reports sexual risk in a very high risk—in some of our high risk venues, we will then do what’s called pooled NAT testing, so essentially we’ll be checking viral load levels to see if the RNA is detectable in their blood. And in some—two of our sites where STD program has been working with for several years, you know, one in 200 is actually the kind of overall rate of acutes that are detected, and it increased our rate of detection of HIV overall by 12 percent. So it’s actually an important piece of—and as you point out, it will continue to be important.
MERMIN: It will, and just a clarification there. Several health departments that also are exploring this, for example in North Carolina, they’ve explored identifying people with acute HIV infection and then contacting their partners, which is a traditional public health service to let folks who have had exposure to someone with HIV through sexual contact, to let them know that that’s happened so that they should get tested. And those programs have been found to be cost effective, and maybe some of the new technologies will allow them to become more common so that as you said, if we can do a better job of diagnosing people and linking them into care, and acute infection becomes even more important from a public health standpoint, we’ll be able to actually address it more effectively. Second question, please?
UNIDENTIFIED PARTICIPANT: There’s been a lot of focus on African-American men who sleep with men, because of the increase of infections. But I’m also wondering if there’s been an increase in women, specifically African American women, and how some of the campaigns are targeting that population and beyond that, the studies have been in 21 cities, but have there been studies in rural areas where rates of death are so high, because their needs are so different versus urban needs?
MERMIN: Thank you for that question. Perhaps Dr. Hall, you could clarify about the core surveillance system that CDC conducts.
HALL: Right, so from the surveillance data, we do not see increases among women. We see neither in diagnoses nor in incidents, so—
MERMIN: I would say that—so right now, it’s true. We don’t see increasing proportions or increasing rates of HIV infection among women. However, in our recent estimates of new HIV infections in 2009, 23 percent of new infections were among women. And because of that, that’s a major concern to CDC and to many of the health departments. Women at risk for HIV infection and with HIV infection have special needs, not only because of pregnancy and (perinatal) transmission reduction interventions, but also because the contextual framework for protecting yourself from HIV can often be more complex and more difficult for women than it can be for some men, especially for minority women, and women living in low socio-economic areas where it appears the epidemic among women can be worse than in other areas.
So we are very interested in making sure that we continue to work with women and perhaps present information both from a surveillance standpoint more readily to the public, so that they can examine the data themselves, and that our programs actually for women are being expanded. And we have several different behavioral interventions that help women learn how to protect themselves from HIV, both at group levels and community levels, that we’re supporting through health departments and community-based organizations, but there’s probably more we can do. And we’re going to be exploring some of those issues over the next year.
Oh, sorry, are there any questions over the phone?
OPERATOR: Yes, there are. And our first question here will come from the line of Michael Smith. Please go ahead.
MICHAEL SMITH: Yes, a question actually for Dr. Hall. I’m trying to understand the issue of the definition of retained in care. And this seems to be—the definition you’re using is at least one CD4 or viral load test in the previous year. If someone hasn’t had those tests, does that mean they are not in fact being treated with antiretrovirals, or—I’m trying to get a sense of how many of these people actually are not getting any treatment at all, or just—
HALL: Go ahead.
SMITH: I’m finished.
HALL: So, we think that the CD4 or viral load measures are a marker for being in care, and so we would make the assumption that probably those who are not measured are not in care. As part of care, the health care provider would always do at least a viral load measure to see whether care is effective, so from what we are seeing is that overall, too few people with HIV are in care, that is about 41 percent are not in care and they are most likely not receiving treatment.
MERMIN: OK, maybe a second question on the phone?
OPERATOR: Sure. And that will come from Mandy Gardner, please go ahead.
MANDY GARDNER: Hi, thanks for taking my question. Just quickly, I’m wondering is all or any of this research new in terms of being newly released? Have we heard this data before?
MERMIN: I think much of it is new, actually. And everyone—well, yes, it is new.
GARDNER: OK, OK. Thank you.
MERMIN: My pleasure. Any other questions on the phone?
OPERATOR: We do have one question—one more question. That comes from Damian McNamara. Please go ahead.
DAMIAN MCNAMARA: Hi, I’m calling from Miami. I am a writer for “Hospitalist News” and “Internal Medicine News” and some other physician publications. My question is for Dr. Avery, could you just give me your take-home message for hospitalists who are working in a hospital system that has an EMR, but may not have this sort of prompt already to do the routine HIV screening?
AVERY: My recommendation would be that they get one. No, I think that using the electronic medical record to the providers’ advantage is extremely helpful to use the record to review prior history and use clinical decision-making tools to—or clinical decision-making support tools in order to improve provider care is an important aspect of the electronic medical record.
MERMIN: Thank you. Are there any other questions on the phone?
OPERATOR: No further questions from the phone lines at this time.
MERMIN: Great, thank you. I think we have one more question from someone in the room. Bob is back.
ROEHR: Yes, well, can’t shut me up, I guess, if you have time. With the implementation of the affordable care act, and there’s going to be a package of prevention services that have—that are required for all health care insurers and everything. Is that going to help speed up the routinization of it? Right now, it’s been adopted for women, there are not necessarily broader guidelines yet covering everyone. Is this going to speed up the conversion for routine testing everywhere?
MERMIN: I actually would turn to any of the panelists, if they have some thoughts on that.
SAYLES: I mean, I would just say that currently, the United States preventative service task force, and all of the routine screening that will be covered under the affordable care act, have to receive, you know, high grades under their review. And so the routine testing data had not been reviewed by them since, I want to say it was—it was either—I think it was 2007. And so that’s really been a request for a re-review of that information, so that we can understand, in light of new evidence both you know of cost effectiveness and other data, whether or not it will actually reach those standards that, you know, to be a supported preventative service, and I think obviously most of our hope would be that that will reach that level of review and be included.
MERMIN: And I would just add that I think your question is apropos to some of the—to our—to our changing time. To make a difference in practice, you need to have appropriate guidelines and recommendations, you need to have reimbursement for services that are provided, and you need to have practitioners implementing the new interventions. And all three of those are important in terms of actually having these interventions be brought to scale, and you can see some examples in all areas from everyone in this panel, where if you forget one of those areas, then you have gaps in service. And so having an expanded health care system in the United States that can support some of these important HIV care and prevention interventions will be important for all people with HIV, and people at risk for HIV.
OK, I think that’s the end of our press conference, and thank you very much for participating. Thank you to all the panelists.
OPERATOR: Thank you, and that does conclude our conference for today. This call has been recorded and will be made available for replay beginning at 3 p.m. Eastern Daylight Time today, and running through 11:59 Eastern on August 23rd. You may access the recording by dialing (800) 475-6701 from the United States, or (320) 365-3844 and entering the access code 213105.
Once again, thank you for your participation. You may now disconnect.