The State of People Living with HIV/AIDS

Richard J. Wolitski, PhDDeputy Director, Behavioral and Social Science

HHS Consultation with People Living with HIV/AIDSJuly 25, 2011

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of HIV/AIDS Prevention

Overview

□ Who We Are

□ Some of Our Challenges

□ Some of Our Strengths

WHO WE ARE

Hall et al., JAMA, 2008. Campsmith et al., CROI, 2009.

HIV INCIDENCE AND PREVALENCE, UNITED STATES, 1977-2006

1,178,350

People Living with HIV/AIDSIn the United States

At the end of 2008. CDC, MMWR, June 3, 2011.

Gender

CDC, MMWR, June 3, 2011

25%

75%

Female

Male

Transmission Risk

49%

29%

17%

5% 1%

MSM

Heterosexual

IDU

MSM/IDU

Other

CDC, MMWR, June 3, 2011

0.40% 1.40%

46.00%

17.00%

34.00%

AI/AN API Black/Af AmHispanic White

Race/Ethnicity

CDC, MMWR, June 3, 2011

Age

6%

15%

30%33%

16%

13-2425-3435-4445-5455+

CDC, MMWR, June 3, 2011

Too Many PLWHA Don’t Know They Have HIV

□ 236,400 people living with HIV/AIDS have not been diagnosed□ 20% of people living with

HIV/AIDS

□ Heterosexual men, MSM, youth, API and AI/AN at greatest risk of undiagnosed infection

CDC, MMWR, June 3, 2011

Undiagnosed HIV Infection is a Threatto Public Health and the Health of PLWHA

□ Not able to access HIV care and treatment

□ At greater risk for HIV transmission

□ At greater risk for disease progression and death

SOME OF OUR CHALLENGES

Some Challenges: Acquiring HIV

□ Poverty□ Homelessness□ Depression and other mental health issues□ Substance use and abuse□ Physical and sexual abuse□ Racism□ Homophobia□ Transphobia□ Gender inequality

Some Challenges: Coping with HIV

□ Depression and other mental health issues□ Getting appropriate medical care and

supportive services□ Disclosure and nondisclosure of HIV status□ HIV stigma and discrimination□ Violence□ Employment□ Housing

Bhaatia et al., AIDS and Behavior, 2011.

• 180 people diagnosed with HIV in past 90 days– Houston, Texas– Not already linked to care

• 67% screened positive for depression• 56% of depressed and 68% of not depressed

persons linked to care during study

Many PLWHA Are Not Getting Appropriate Medical Care

Gardner et al. CID. 2011.

4 out of 5 diagnosed

Gardner et al. CID. 2011.

75% linked to care

Many PLWHA Are Not Getting Appropriate Medical Care

Gardner et al. CID. 2011.

67% retained in care

Many PLWHA Are Not Getting Appropriate Medical Care

Gardner et al. CID. 2011.

75% on ART

Many PLWHA Are Not Getting Appropriate Medical Care

Gardner et al. CID. 2011.

80% undetectable

Many PLWHA Are Not Getting Appropriate Medical Care

Gardner et al. CID. 2011.

24% of diagnosed undetectable

Many PLWHA Are Not Getting Appropriate Medical Care

Gardner et al. CID. 2011.

19% of all PLWHA

Many PLWHA Are Not Getting Appropriate Medical Care

Good HIV CareIs Good for Prevention

• Higher viral load associated with HIV transmission (Fisher et al., AIDS, 2010; Das et al., PLOS One, 2010; Quinn et al., N Eng J Med, 2000)

• Early ART led to 96% reduction in transmission in HPTN 052 (Cohen et al., NEJM 2011)

• 92% reduction in observational studies (Attia et al., AIDS, 2009)

• Inadequate or late health care increases morbidity and mortality

• People living with HIV are at-risk for various health problems including:– Cardiovascular disease– Cervical and anal cancers– Bone loss– Dementia– Sexually transmitted infections– Hepatitis C

Good HIV Care

Is Good for PLWHA

Stigma Has Declined, But Still Widespread

Kaiser Family Foundation, June 2011.

• 45% of Americans would be uncomfortable having their food prepared by someone who is HIV‐positive

• 29% uncomfortable having their child in a classroom with an HIV‐positive teacher

• 18% uncomfortable working with someone with HIV

Gielen, et al. Journal of Urban Health, 2000.

• 257 HIV-positive women, 92% African American– 44% reported negative consequences of disclosure

• 24% lost friends • 23% insulted or sworn at • 21% rejected by family

– 10 women (4%) were physically or sexually assaulted– Women with a history of physical and sexual violence

were significantly more likely to experience negative consequences

Wolitski et al., AIDS and Behavior, 2009.

• 637 unstably housed/homeless PLWHA from 3 US cities

• Higher levels of stigma associated with:– Poorer self-assessed physical and mental health– Poorer adherence to HIV treatment– Drug use– Decreased disclosure of HIV status to social network

members and sex partners

Galvan et al., AIDS Patient Care and STDs, 2008,

• 283 HIV-positive African Americans in Los Angeles

• Less perceived stigma associated with fewer symptoms of major depression

• Social support from friends associated with less perceived stigma

Courtenay-Quirk et al., AIDS Education and Prevention, 2006.

• 206 HIV-positive MSM from New York City and San Francisco

• Many perceived stigma and discrimination in gay community toward PLWHA– 36% agreed that HIV-negative men judge you if they find

out that you are positive

Courtenay-Quirk et al., AIDS Education and Prevention, 2006.

• Higher levels of stigma were associated with:– Anxiety, loneliness and depressive symptoms– Suicidal ideation– Avoidant coping– Seeking partners in sex clubs and private sex parties

SOME OF OUR STRENGTHS

Some Strengths

• Individual and collective resilience• Strength, courage, knowledge and ability to

bring about positive change:– Advocating for our needs and those of others– Helping others navigate complex medical care and

service systems– Sharing our stories and experiences to:

• Reduce stigma and discrimination• Educate others and prevent HIV transmission• Improve medical care and service delivery

– Providing leadership at community and national levels

Item (n = 242 HIV+ MSM, USA) Agree orStrongly Agree

It’s very important for me to protect my sex partners from HIV.

82%

HIV positive gay men have a special responsibility to keep other gay men from becoming positive.

77%

It’s my partner’s responsibility to tell me if he wants to use a condom.

22%

It should be the responsibility of someone who is HIV negative—not someone who is positive—to make sure that sex is safe.

17%

Wolitski et al., AIDS and Behavior, 1998.

Most PLWHA See Themselves as Responsible for Protecting Others

Perceived Responsibility is Associatedwith Transmission Risk

11

22

63

3745

78

0

20

40

60

80

UnprotectedInsertive Anal

Sex

UnprotectedReceptive Anal

Sex

UnprotectedInsertive Oral

Sex

Perc

ent

High

Low

p < .001p < .001 p < .05

Wolitski et al., AIDS and Behavior, 1998.

A Growing Literature

• Personal responsibility is associated with reduced risk in multiple studies– Injecting and other drug users in the US and

Tanzania (Latka et al., 2007; Ross et al., 2007)

– Ugandan men and women (King et al., 2008)

– MSM in The Netherlands and US (Bogart et al., 2006; O’Dell et al., 2008; van Kesteren et al., 2005, 2007)

– HIV+ clinic patients in US (Hong et al., 2006)

Psychological Bulletin. 2009.

Kimbrough et al., AJPH, 2009.

• 422 recruiters in 7 cities referred people they knew for HIV testing– 60% living with HIV/AIDS– More undiagnosed HIV infections found by PLWHA

• 6.8% referred by PLWHA were newly diagnosed with HIV• 4.4% referred by HIV-negative persons were newly

diagnosed

Women and Men Living with HIV/AIDSHelp Others Reduce Risk Behavior

Wingood et al., JAIDS, 2004; Kalichman et al. American Journal of Preventive Medicine, 2001.

More info available at: www.effectiveinterventions.org

Women and Men Living with HIV/AIDSHelp Others Reduce Risk Behavior

Conclusions

• PLWHA are a large, growing and diverse population– Face multiple challenges– Countered by multiple strengths

• The health care needs of PLWHA are not being adequately met and result in– Poorer health for PLWHA and increased health care costs– Missed opportunities to prevent HIV transmission

• Stigma and discrimination continue to negatively affect the lives and health of PLWHA

• PLWHA play important and effective roles in reducing stigma, improving HIV care and preventing HIV transmission

Thank You!

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of HIV/AIDS Prevention