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  Roger K Hershline, PhD, MD

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  Cure HIV, Inc.

HIV Prevention in the 3rd Decade or The Changing Epidemic

The HIV/AIDS epidemic has taken a tremendous toll on people in the United States. From the beginning of the epidemic in 1981 through 2003, an estimated 1.3–1.4 million people in this country have been infected with HIV/AIDS. Of these, about one third (more than 500,000) have died.

Despite declines in new infections in the early 1990s, more people are living with HIV/AIDS than ever before. CDC estimates that about 1 million people in the United States are living with HIV or AIDS. About one quarter of these people are unaware of their infection, which puts them and others at risk. Those who do not know that they are infected cannot take advantage of treatment and may unknowingly transmit HIV to others. And even of the three quarters who know that they are HIV-infected, one third may not be receiving ongoing care. About half of all HIV-infected people may be untested, untreated, or both.

How Is It Changing?

The epidemic is changing in terms of how many people are living with HIV, where they are living, who is most vulnerable, and how we track the epidemic.

• More people are living with HIV. Because of treatment advances, people with HIV are living longer. As a result, more people are living with HIV today than at any other time during the history of the epidemic. Along with this growing population of HIV-infected persons, chances for transmission are increasing.
• The epidemic keeps moving. The HIV/AIDS epidemic varies considerably across the country, not only by region, but within regions and states, and even within communities. Currently (as well as for the past several years), many people with AIDS live in rural areas or small cities in the South.
• Populations affected are changing. In addition to the groups who have been at highest risk since the beginning of the epidemic - MSM and IDUs - other groups are also at risk for HIV.
  • Racial and ethnic minorities. The epidemic has expanded from primarily affecting white people to primarily affecting people of color.
  • Women. More than half of heterosexually acquired HIV infections occur in women.
  • Youth. New generations are replacing those who benefited from early prevention strategies.
• Tracking the epidemic is more complex. Early on, CDC tracked the epidemic by monitoring new AIDS cases. Today,
  trends in the epidemic are better reflected by new HIV infections, which are more difficult to track. New HIV infections cannot be measured directly because many newly infected people do not get tested and because a positive test result alone does not indicate whether the infection is recent.

People who are HIV-infected

MMP (Morbidity Monitoring Project) is a new surveillance system designed to collect information from HIV/AIDS patients who received care from randomly selected HIV care providers. In 2004, CDC awarded funds to 20 states and 6 cities for this project. MMP collects information about access to and use of HIV care, treatment, and prevention services and prevalence of behaviors that can result in HIV transmission and affect disease outcomes (like adherence to therapy). Information is collected from medical records and patient interviews. Patients are selected in a way that will make the data nationally representative for persons who are living with HIV/AIDS and receiving care. Data for planning, evaluation, monitoring, and allocation of resources will be available by the end of 2006.

HITS (HIV Testing Survey) primarily interviewed adults who were not HIV-infected but were at high risk for HIV infection. HITS collected information about what motivates people to get tested for HIV and what behaviors place people at risk for HIV. HITS was conducted in 24 states during 1995–2003. Data analyses from HITS are ongoing.

Microbicides

CDC is actively involved in research to identify and test potential HIV microbicides. Microbicides are gels, creams, or suppositories that can kill or neutralize viruses and bacteria. When applied in the vagina before sexual intercourse, they can protect against some sexually transmitted diseases. A safe, effective, and affordable microbicide against HIV could help to prevent many new infections.

United States

CDC is conducting preclinical (animals and laboratory) and Phases I and II clinical trials of potential new HIV microbicides. In its own laboratories, CDC is also examining the toxicity and efficacy of some microbicides against HIV.

Trends among Heterosexual Adults

Historically, the HIV/AIDS epidemic has affected more men than women, but women are being increasingly affected. Since 1985 the proportion of estimated AIDS cases diagnosed among women has more than tripled, from 8% in 1985 to 27% in 2003.

AIDS

The epidemic has increased most dramatically among women of color. Although black and Hispanic women together represent about one fourth of all US women, they account for more than three fourths of estimated AIDS cases diagnosed to date among US women. In 2003, black and Hispanic women represented an even greater proportion (83%) of diagnosed cases in women.

Despite continuing decreases in HIV/AIDS-related deaths in men and women, HIV/AIDS remains the fifth leading cause of death in the United States for men and women aged 35–44 years and one of the top 10 leading causes of death for men and women aged 20–54. For blacks in these age groups, HIV/AIDS ranks even higher as a cause of death.

HIV

Although each year more men than women become infected with HIV, this gap is slowly closing. Data from the 25 states with longstanding HIV reporting show that new HIV diagnoses in men declined 27% from 1994 through 2003.

Transmission routes differ by gender. Data from 2003 show that

• among men, HIV transmission is estimated to occur 63% through sexual contact with men, 14% through injection drug use, and 17% through sexual contact with women.
• among women, HIV transmission is estimated to occur 79% through sexual contact with men (many of whom are IDUs or also have sexual contact with men) and 19% through injection drug use.

Data source: Centers for Disease Control & Prevention Website