1. HIV Prevention
Centers for Disease Control and Prevention

2. Burden of HIV in the United States
 1.1 million people living with HIV
 Net increase of 40,000 people with HIV infections each
year
 56,000 new infections (2006)
 16,000 deaths (2006)
 HIV infected people who start antiretroviral treatment
(ART) are now expected to live at least an additional 35
years
 Lifetime treatment costs of ~$400,000

3. Number of people living with HIV continues to
increase sharply
HIV Incidence and Prevalence, United States, 1977–2006
1,200,000
New HIV Infections (Incidence)
1,000,000
People Living With HIV/AIDS (Prevalence)
800,000
600,000
400,000
200,000
0
1977
1978
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1981
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1986
1987
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1989
1990
1991
1992
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2006
JAMA 2008;300(5):520-529.Campsmith M, et al. CROI 2009.

4. Stark disparities in HIV/AIDS among different
groups
 95% of people with AIDS are MSM, African
American, Latino, or IDU
 African Americans are 8 times more likely than whites
to have HIV
 Latinos are 3 times more likely to have HIV than whites
 MSM are >40 times more likely to have HIV than other
men and women
CDC, HIV Surveillance Report,2008. Published June 2010. www.cdc.gov/hiv/surveillance/resources/reports
MSM = Men having sex with men
IDU = Intravenous drug users

5. From 2005-2008, the percentage of HIV diagnoses
attributed to male-to-male sexual contact
increased — 37 states and 5 U.S. dependent areas
Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis.
Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005.
All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and
missing risk-factor information, but not for incomplete reporting.
1Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
2 Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

6. In 2008, the majority of HIV diagnoses among males were attributed to
male-to-male sexual contact; among females the majority were
attributed to heterosexual contact — 37 states and 5 U.S. dependent
areas
Males
N=31,595
4%
15%
72%
Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis.
Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005.
All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and
missing risk-factor information, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.

7. From 2005-2008, the percentage of HIV diagnoses
increased among Blacks/African Americans – 37 states
and 5 U.S. dependent areas
,%
Note: Data include adults and adolescents with a diagnosis of HIV infection regardless of stage of disease at diagnosis.
Data from 37 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2005.
All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not
for incomplete reporting.
a Hispanics/Latinos can be of any race.

8. HIV prevention works
Saves lives and money
 Our collective prevention efforts have led to a
dramatic reduction in HIV infections
• Estimated number of new HIV infections per year was 130,000 in
1985
• Down to an estimated 56,000 new HIV infections per year in 2006
 Conservative estimates are that prevention
efforts have:
• Averted more than 350,000 HIV infections in the United States
• Saved more than $125 billion in medical costs
Source: Holtgrave DR. Written testimony on HIV/AIDS incidence and prevention for the US House of Representatives Committee on
Oversight and Government Reform. September 16, 2008.

9. Key HIV prevention strategies
Promote:
 Abstinence (or delaying sex)
 Fewer sexual partners (ideally, monogamous
relationship with an uninfected partner)
 Consistent and correct use of condoms
(male/female)
 Not sharing syringes for injection drug use

10. Cost benefits of HIV prevention
Pennies ~$400,000
Cost of condoms Lifetime cost of
treating one HIV-
infected person

11. Other HIV prevention strategies
 Antiretroviral drugs (ARVs):
• To prevent perinatal
transmission
• To reduce infectiousness
• To prevent new infections (as
Pre-Exposure Prophylaxis
[PrEP])
 Male circumcision
• To reduce risk of HIV infection
through penile-vaginal sex

12. Pre-Exposure Prophylaxis (PrEP)
 Potential users: HIV-uninfected persons at high
risk of becoming infected
• High risk may include sexual partner who has HIV, multiple
partners, frequent STDs, or other evidence of high risk
• Recent trial demonstrates the safety and efficacy of PrEP for MSM
at high risk
 Cost-effectiveness depends on:
• HIV incidence in target groups
• Cost of medication and services
• Ability to maintain or increase existing risk reduction behavior
• Adherence to medication
• $34,000-$320,000 per QALY saved
Source: Paltiel et al. CID 2009:48(6):806-816 Smith, et al. MMWR 2011:60(03);65-68

13. PrEP with daily tenofovir/emtracitabine can
reduce HIV risk in MSM
44% reduction in acquisition
Source: Grant RM et al. (2010). NEJM; published online Nov. 23, 2010.

14. Policy, Systems, and Environmental Change
Integrating Prevention and Healthcare
Policy development and support
 Guidelines and recommendations (testing, prevention
with positives, ART)
 Quality measures: Development and uptake
 Reimbursement coding guidance

15. Policy, Systems, and Environmental Change
Integrating Prevention and Healthcare
New programs and models
 Expanded Testing Initiative: 30 jurisdictions covering
>90% of epidemic
• Over 2.6 million HIV tests conducted; 27,000 HIV infections
diagnosed
 Enhanced HIV Prevention Planning: 12 urban areas
covering 44% of epidemic
• Integrating HIV prevention, care, treatment services across health
care system and community

16. Testing and diagnosis is prevention
 21% (230,000) with
undiagnosed HIV
• Account for approximately
50% of new HIV
transmissions
 79% (870,000) with
diagnosed HIV
• More likely than
undiagnosed to access
prevention and treatment
Source: Marks G, et al (2006). AIDS 20(10): 1447-1450.

17. HIV testing is a prevention strategy
 CDC’s 2006 HIV Testing Recommendations for Health
Care Settings
• Promote routine screening of patients age 13-64
Routine, opt-out screening in clinical settings
costs $2,000-$6,000 per HIV diagnosis
confirmed
Source: Campsmith M et al. (2010). JAIDS 53:619--24.

18. Key approaches and program considerations in
HIV prevention
 HIV testing and linkage to care
 Prevention with positives
 Policy and structural interventions
 Targeted interventions
 Surveillance, monitoring, and evaluation
 Evidence-based planning
 Health equity
 Health reform
 Program collaboration and service integration

19. Focusing resources
 Burden of disease
• Geographic distribution
• Groups disproportionately affected by HIV (MSM, African
Americans, Latinos, injection drug users)
 HIV prevention services
• For people living with HIV
• For people at high risk for HIV infection
 Monitoring the epidemic, sharing, and using
information
 Discovering and operationalizing new interventions

20. Maximizing impact
 Target programs to people and geographic areas most
at risk for transmission or acquisition
 Focus on interventions with evidence for large effect
size
 Choose feasible efforts with potential for large-scale
implementation

21. ―The United States will become a place where new HIV
infections are rare and when they do occur, every
person, regardless of age, gender, race/ethnicity, sexual
orientation, gender identity or socio-economic
circumstance, will have unfettered access to high
quality, life-extending care, free from stigma and
discrimination.‖
—Vision of the National HIV/AIDS Strategy