hiv prevention in the biomedical era, presented by brett palmer

Regional Resource Network Program U.S. Department of Health & Human Services

HIV Prevention in the Biomedical Era

Thursday, August 27, 2014

Brett J. Palmer, MEdRegional Resource Coordinator HIV/AIDS

U.S. Department of Health and Human Services

Office of the Assistant Secretary for Health

Region III – DE, DC, MD, PA, VA, WV


Regional Resource Network Program

Goals• Educate and promote to regional HIV/AIDS stakeholders, both

governmental and non-governmental, the:• National HIV/AIDS Strategy (NHAS) • Affordable Care Act• Viral Hepatitis• HIV/AIDS Treatment Cascade Model

• Foster or facilitate increased opportunities among regional stakeholders for better local coordination in HIV/AIDS prevention, planning, and service delivery consistent with the NHAS’s priorities and principles.


Presentation Overview


1. What has changed in federal prevention funding?

2. What is biomedical HIV prevention?

3. Why a shift to biomedical prevention?

4. Three major policies impacting biomedical prevention.


Kaiser Family Foundation - U.S. Federal Funding for HIV/AIDS: The President’s FY 2015 Budget Request

http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-the-presidents-fy-2015-budget-request /

http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-the-presidents-fy-2015-budget-request/

http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-the-presidents-fy-2015-budget-request/


Biomedical Prevention: Male Circumcision

For men, lowers the risk of: • Acquiring HIV from female

partner• STDs • Penile cancer• Infant urinary tract infection

For women, lowers the risk of:• HPV and cervical cancer• Genital ulceration• Bacterial vaginosis• Trichomoniasis

Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/malecircumcision/index.html

http://www.cdc.gov/hiv/prevention/research/malecircumcision/index.html

http://www.cdc.gov/hiv/prevention/research/malecircumcision/index.html


Biomedical Prevention:Pre-Exposure Prophylaxis (PrEP)

Medication to reduce risk for non-positive people:• Daily pill

Used consistently:• Effective in MSM, MSW, WSM

Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/prep/index.html

http://www.cdc.gov/hiv/prevention/research/prep/index.html

http://www.cdc.gov/hiv/prevention/research/prep/index.html


Biomedical Prevention:Treatment as Prevention

Full prevention benefit of treating HIV infection, four tenets:• HIV testing is foundation for both prevention and care efforts • Early identification of infection empowers individuals to take action• Early treatment reduces risk of transmitting HIV to others • Prevention benefit of treatment can only be realized with the

continuum of care

ART as prevention may be promising if:

1. Widespread testing and early identification of infected persons

2. Ongoing counseling to support maintenance of safer sexual behaviors

3. Adequate clinical follow-up to monitor for adverse effects of ART

4. Geographic and financial accessibility of treatment for affected persons

Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/tap/index.html

Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/art/index.html

http://www.cdc.gov/hiv/prevention/research/tap/index.html

http://www.cdc.gov/hiv/prevention/research/tap/index.html

http://www.cdc.gov/hiv/prevention/research/art/index.html

http://www.cdc.gov/hiv/prevention/research/art/index.html


Why a Biomedical Approach:HIV Cost-Effectiveness

HIV testing cost per

new diagnosis • In health care settings:

$1,900 – $10,000• In non-health care settings:

$10,334 – $20,413

Cost of HIV treatment• Annual: $23,000 • Lifetime: $379,668

Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/index.html

http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/index.html

http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/index.html


Annual HIV-related healthcare costs

Acute HIV 10–500

Asymptomatic HIV – Untreated 3,000–6,000

Symptomatic HIV – Untreated 5,000–9,000

Symptomatic HIV – Treated with ART (excludes ART costs) 5,000–7,000

AIDS – Untreated 15,000–26,000

AIDS – Treated with ART (excludes ART costs) 6,000–17,000

Annual non-HIV-related healthcare costs for uninfected and infected individuals 3,000–6,000

Annual cost of ART 12,500–19,000

Cost of PrEP

TDF/FTC (30-day supply) 300–1,118

STI testing 25–75

Blood urea nitrogen and serum creatinine testing 10–40

Physician visit 10–200

Cost of HIV testing and counseling – Antibody test

Uninfected 5–25

HIV-infected 50–100

Pre-test counseling 0–100

Post-test counseling for HIV-negative persons 0–50

Post-test linkage/counseling for HIV-positive persons 0–100

Cost of HIV diagnosis 125–1,200

The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in Men Who Have Sex with Men in the United States; Jessie L. Juusola, Margaret L. Brandeau, Douglas K. Owens, Eran Bendavid; Ann Intern Med. 2012 April 17; 156(8): 541–550. doi: 10.1059/0003-4819-156-8-201204170-00001; PMCID: PMC3690921








1. Routine HIV Testing

2. Affordable Care Act

3. Continuum of Care


Routine HIV Testing in Medical Settings:The U.S. Preventive Services Task Force

Rationale:• Identification and treatment of HIV infection means reduced risk of:

• HIV progression to AIDS• AIDS-related events • Death in individuals with immunologically advanced disease

• Earlier ART means reduced risk for AIDS-related events or death• ART decreases risk for transmission from HIV-positive persons • Identification and treatment of HIV-positive pregnant women reduces

rates of mother-to-child transmission• “The overall benefits of screening for HIV infection in adolescents,

adults, and pregnant women are substantial”

U.S. Preventive Service Task Force: Screening for HIV: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm

http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm




Recommendations:• Clinicians screen for HIV infection in adolescents and adults ages 15

to 65• Younger adolescents and older adults who are at increased risk

should also be screened• Clinicians screen all pregnant women for HIV






Screening intervals:• One-time screening of adolescent and adult patients • Repeated screening:

• “At lease annually” for those who are very high risk:• Men who have sex with men • Active injection drug users

• “Somewhat longer intervals” (3–5 years) for those at increased risk based on behavioral risk factors:

• Having unprotected vaginal or anal intercourse • Having sexual partners who are HIV-infected, bisexual, or

injection drug users • Exchanging sex for drugs or money





http://kff.org/report-section/assessing-the-impact-of-the-affordable-care-act-on-health-insurance-coverage-of-people-with-hiv-issue-brief/





The Affordable Care Act:Improving Access to Coverage

Insurers can no longer: • Deny coverage to anyone based on pre-existing conditions • Impose annual limits on coverage or lifetime caps on insurance

benefits

Tax subsidies available:• Based on financial need• Only through the Health Insurance Marketplaces

Medicaid expansion:• Not available in all states

Prescription benefits:• Closing the Medicare Part D prescription drug benefit “donut hole”• AIDS Drug Assistance Program

AIDS.GOV: http://aids.gov/federal-resources/policies/health-care-reform/

http://aids.gov/federal-resources/policies/health-care-reform/



The Affordable Care Act:Ensuring Quality Coverage

Better information • Plans must provide user-

friendly information

Quality, comprehensive care • 10 essential health benefits

Preventive care • HIV screening

Coordinated care • Patient-centered medical home

model of care





The Affordable Care Act:Preventive Health Services

Free Preventive health services for adults• HIV screening for everyone ages 15 to 65, and other ages at

increased risk

Free Preventive health services for women• HIV screening and counseling for sexually active women

Free Preventive health services for children• HIV screening for adolescents at higher risk





The Affordable Care Act: Enhancing the Capacity of the

Health Care System

Major investments• Community health centers to provide more opportunities for HIV care

delivery

Technical assistance • Help those not providing HIV care to develop the capacity to do so• Especially in minority communities

Expand capacity • To deliver culturally competent care to populations heavily impacted

by HIV• National LGBT Health Education Center funded by HRSA





The Affordable Care Act:Increasing Opportunities for Health

and Well-Being

Prevention and wellness • Investments in prevention, wellness, and public health activities• Improve public health surveillance, community-based programs, and

outreach efforts • Increase coverage for HIV testing

Diversity and cultural competency • Expand cultural competency training for health care providers• Ensure all populations are treated equitably

Health care providers for underserved communities • Expand the health care workforce• Increase funding for community health centers





What is the HIV/AIDS Care Continuum

Model used to identify issues related to improving services for people living with HIV:

• HIV Diagnosis• Linked to Care• Retained in Care• Prescribed ART• Virally Suppressed

AIDS.gov: http://aids.gov/federal-resources/policies/care-continuum/

http://aids.gov/federal-resources/policies/care-continuum/



HIV/AIDS Care Continuum Uses

How is the HIV care continuum being used?

• Federal level:• Inform how best to prioritize

and target available resources

• Monitor national progress • State and local levels:

• Assess where resources are needed

• Target resources accordingly





Importance of the HIV/AIDS Care Continuum

Why is the HIV Care Continuum important?

• Pinpoint where gaps exist• Better health for people living

with HIV/AIDS• Helps achieve goals of the

NHAS





Challenges of the HIV/AIDS Care Continuum

Challenges Developing an HIV/AIDS Care Continuum

• Collection of data• Lack of resources at the state

and local level





HIV/AIDS Care Continuum Example

Hivcontinuum.org: http://hivcontinuum.org/city-complete.html?city=Philadelphia,%20PA&cd=phl

http://hivcontinuum.org/city-complete.html?city=Philadelphia,%20PA&cd=phl

http://hivcontinuum.org/city-complete.html?city=Philadelphia,%20PA&cd=phl




1. What has changed in federal prevention funding?• HIV funding has increased for care and remained steady for

prevention. However, as the epidemic expands, the limited resources available are being distributed to more locations.

2. What is biomedical HIV prevention?• PrEP • Treatment as Prevention• Male Circumcision• Testing in Clinical Settings



HIV Prevention in the Biomedical Era, Continued

3. Why a shift to biomedical prevention?• Many cost effectiveness analysis indicate that prevention in a

clinical setting is less expensive than prevention at CBO/ASOs

4. Three major policies impacting biomedical prevention.• Routine HIV Testing • Affordable Care Act• Continuum of Care

hiv prevention in the biomedical era, presented by brett palmer

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