Jono’s Journal

I am pleased to have worked at DHAP for the past 6 weeks. During this time, I have had the opportunity to meet staff and partners, and to talk with colleagues at other Divisions throughout CDC. I appreciate the candid and insightful ideas that were presented from throughout the division. I welcome additional thoughts on improving HIV prevention in the United States and DHAP operations. Within the next couple of weeks, we will be establishing a standardized process for submitting your perspectives and ideas.

I appreciate the talented leadership and thoughtful ideas from Drs. Rich Wolitski and Kevin Fenton, and other division and branch leaders, which have enabled DHAP to run smoothly over the past few months and allow an effective transition. We will be initiating a formal strategic planning process this year that will incorporate suggestions from the recent external review, partner organizations, other divisions, and DHAP staff, as well as current prevention science, surveillance information, and program experience.

DHAP is an outstanding organization of thoughtful, committed people involved in the highest quality science, communications, policy, surveillance, research, and program implementation. Working closely with our grantees, partners, and other federal agencies has always been—and will continue to be—vital as we confront the challenges and complexities of HIV prevention in a world of health disparities and economic difficulties. To bring HIV prevention to the scale and scientific creativity and quality it deserves, we must effectively use new and existing resources as well as leverage the resources of our partners. I look forward to working with all of you to address challenges, and to effectively use the knowledge and resources we have to prevent HIV infections throughout the country.

In this issue of DHAP News, learn more about what’s in store for those of us attending the 6th National HIV Prevention Conference now just a week away; find out what’s happening on the Act Against AIDS front—and what has been accomplished in the campaign’s first 90 days; see what evidence-based behavioral interventions are being added to the Procedural Guidance for Community-Based Organizations; and take a look at the resources you will find on a new Web site on social determinants of health.

Jonathan Mermin, MD, MPH
Director
Division of HIV/AIDS Prevention

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2009 National HIV Prevention Conference Promises Innovation, Diversity

The 2009 National HIV Prevention Conference (NHPC), August 23–26, in Atlanta brings together HIV prevention experts and advocates from diverse backgrounds and communities nationwide and covers the entire spectrum of HIV prevention—from science to programs.

The conference, the sixth since NHPC was first convened in 1999, offers opportunities to share effective prevention approaches and research findings among governmental, community, and academic partners and to strengthen collaborations between program practitioners and researchers.

Reflecting the theme of “Innovation and Action to End the Epidemic,” the conference schedule promises innovative and interactive sessions and discussions on enhancing behavioral and biomedical interventions, monitoring the epidemic, implementing rapid and reliable tests for early HIV diagnosis, and improving access to early treatment and prevention services for persons with HIV.

Innovative thinking has driven the planning of the conference, from the decision to save money and protect the environment by “going green,” to the online aspects of the conference, to the inclusion of new researchers and information on populations that haven’t been included in previous conferences.

Participants will be able to access the conference program and abstract book online, and this information will also be available on a CD. The evaluation of the conference will also be online. Other online components of this conference include

• A session search assistant that will make it easier for participants to find information about particular sessions they are interested in attending
• New and improved searchability overall so that participants can more easily find relevant information
• With the online My Schedule At-A-Glance, participants can keep track of the times and locations of the sessions they want to attend each day

According to Bob Kohmescher, conference coordinator, the 2009 NHPC will feature some topics that have not been addressed at the previous five national HIV prevention conferences. New approaches to understanding issues of stigma and discrimination will be examined, and congressional representatives will be on hand to discuss their perceptions of the government’s role in domestic HIV prevention.

The conference covers successes, challenges, and innovations in HIV prevention and takes a closer look at where we are going with domestic HIV prevention. Representatives from federal agencies, other government officials, researchers, and people living with HIV infection and AIDS will provide perspectives on the paths that still need to be charted to have an impact on the epidemic.

Conference highlights include:

• Magic Johnson’s address at the opening session
• A plenary session with Dr. Jonathan Mermin, director of the Division of HIV/AIDS Prevention (DHAP), and other DHAP leaders that will highlight recent activities and new directions in the division
• A plenary session with Secretary of Health and Human Services Kathleen Sebelius and CDC Director Dr. Thomas Frieden
• A town hall session with Jeffrey Crowley, director of the White House Office of National AIDS Policy
• Plenary sessions addressing the interconnections between social and structural factors that affect HIV transmission
• Listening sessions with Dr. Kevin Fenton, director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Dr. Mermin, and other senior staff organized around major transmission routes: male-to-male sexual contact, high-risk heterosexual contact (men and women), and injection drug use; and another session that will address a wide range of other issues affecting HIV prevention efforts

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Act Against AIDS Activities Are Abundant Since April Launch

Since the Act Against AIDS national communication campaignbegan in April, key campaign messages have reached target audiences in a variety of ways—primarily through advertising, news media, partnership networks and initiatives, the 9½ Minutes Web site, social media, and interpersonal outreach.

Some metrics, organized by category, to date are

Advertising

• 9½ Minutes banner ads and traditional ads have been placed in markets across the country. Some of the ads are co-branded with health department partners, including the Miami-Dade County Health Department in Florida, the Minnesota Department of Health, the Virginia Department of Health, the Pennsylvania Department of Health, and the Pennsylvania Department of Public Welfare.
• To date, more than 266 million audience impressions have been generated through transit, online, radio, television, and print ads.
• Banner ads targeting black men who have sex with men (MSM) will be placed in relevant online media outlets soon, and these ads will also be available to partners for co-branding.

News Media

• In April alone, the Act Against AIDS campaign garnered 38 million media impressions, including prominent coverage on CNN, FOX 5 News (in Washington, D.C.), The New York Times, The Washington Post, and USA Today.
• On April 7, the day of the campaign launch, Dr. Kevin Fenton, NCHHSTP director, and Dr. Ian Smith, leader of the 50 Million Pound Challenge, appeared as guests on the Tom Joyner Morning Show.
• As part of the Act Against AIDS campaign, CDC has launched a series of local media roundtable discussions for black journalists in 10 cities across the United States. The first was in Washington, D.C., in June. The roundtables bring together the city’s top journalists, media specialists, community leaders, and CDC experts to discuss the HIV/AIDS crisis in the African American community and explore how to effectively educate the public on the severity of the epidemic.

Partnership Networks and Initiatives

Each Act Against AIDS Leadership Initiative (AAALI) organization has hired a dedicated project coordinator, and DHAP’s Prevention Communication Branch and Capacity Building Branch have provided HIV 101 training.

Each AAALI organization has incorporated HIV into their national conventions, Web sites, publications, conferences, and existing outreach efforts.

AAALI organizations have conducted more than 70 HIV-related activities and 25 chapter trainings, with more than 55,000 participants.

AAALI partners have leveraged their assets to secure at least $150,000 in donated ad placements.

Black AIDS Media Partnership (BAMP)—the first of what is hoped to be a number of private-sector media partnerships to address at-risk populations—has generated to date an estimated 7 million media impressions (the number of people who may have seen an article, heard something on the radio or in a podcast, watched something on television, or read something on a Web page or blog about a particular issue). BAMP, which is convened by CDC and managed by the Kaiser Family Foundation and their media partners, recently launched Greater Than AIDS, a coordinated campaign to reach black Americans with life-saving information about HIV/AIDS and to confront the stigma surrounding the disease.

9½ Minutes Web Site

In the first 80 days of the campaign, the Web site had 52,500 page views.

In the first week, the Web site had 15,000 hits. In subsequent weeks, it has averaged 3,000 hits per week.

In the first 80 days of the campaign, 23,000 subscribers requested e-mail updates.

Phase 2 of the Web site launched the week of June 29. Now visitors can submit their own stories, and they can search for HIV testing sites directly from any page on the site; a series of revolving facts about HIV’s impact appear on each page; and videos of people talking about their personal experiences with HIV/AIDS are available under “Voices of Experience.”

Social Media

• Badges, Web banners, and testing widgets for MySpace and Facebook users have been created so individual users can link to the 9½ Minutes Web site directly from their personal pages.
• Three viral video public service announcements that can be added to video-sharing sites are posted at the 9½ Minutes Web site.

Interpersonal Outreach

• In July, Act Against AIDS (AAA) exhibits were on display at Gay and Black Pride events in Chicago and Detroit. On July 5, about 500 participants visited the AAA booth in Chicago. Discussions were recorded with 12 black MSM who focused on what encouraged them to get tested for HIV and what some of the barriers to getting tested were for them. Videos of these discussions will be distributed to relevant partners in the future. On July 25, about 10,000 persons attending the Pride celebration in Detroit visited the AAA booth. In August, 12,000 persons were expected to attend the Pride event in New York; and in September, 75,000 persons are expected at the Atlanta event. At all these events, attendees will have opportunities to visit AAA exhibits and learn more about the HIV/AIDS epidemic and the crucial role of HIV testing in reducing the number of new infections.
• As part of the Prevention IS Care (PIC) component of the Act Against AIDS campaign—one of three CDC social marketing campaigns directed to health care providers—600 physicians were reached in three training workshops on prevention in care. The campaign seeks to reduce new HIV infections by promoting routine provider screening of transmission behaviors and the delivery of brief transmission prevention messages to patients living with HIV.
• One Test. Two Lives., another campaign directed to health care providers, was promoted through exhibits at the annual meetings of the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives. The campaign aims to further decrease perinatal (mother to child) HIV transmission through early and universal HIV testing of all women in prenatal care. Nearly 36,000 health care providers were also reached through educational content in OB-GYN News.

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New Fact Sheets, Updates Underway

Fact sheets are currently being updated to reflect the latest available HIV/AIDS information and statistics from the HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2007, Vol. 19.

The division’s current fact sheets on HIV/AIDS-related topics are being updated and shortened to a one-page format (front and back) to provide more concise information and for easier distribution. Updated fact sheets on HIV/AIDS among Hispanics/Latinos, HIV/AIDS among African Americans, and HIV/AIDS in the United States and a new fact sheet with regional breakdowns of AIDS cases are planned for debut at the National HIV Prevention Conference.

Additionally, fact sheets on HIV/AIDS among women, youth, and persons aged 50 and older, and on perinatal transmission and substance abuse are being updated with new surveillance information and formatted into the new template.

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Nine EBIs Added to Procedural Guidance and to New CBO FOA

In August, nine evidence-based interventions (EBIs) were added to the Procedural Guidance for Community-Based Organizations to coincide with the release of the new Community-Based Organization (CBO) Funding Opportunity Announcement (FOA).

CBOs can apply for funding to implement these interventions, or they can apply for some of the previously listed interventions. The newly packaged EBIs will be diffused through the Diffusion of Effective Behavioral Interventions (DEBI) project. The recently added EBIs are SIHLE (Sistering, Informing, Healing, Living, and Empowering); WILLOW (Women Involved in Life Learning from Other Women); CLEAR (Choosing Life: Empowerment, Actions, Results); D-Up! (Defend Yourself!); Connect; Project START; Sister-to-Sister; Nia; and SHIELD (Self-Help in Eliminating Life-Threatening Diseases).

Each year, more than 2,200 CBOs receive funding directly from the CDC or through health departments to implement these and other EBIs to fight HIV and AIDS in their communities. The EBIs, supported by DEBI, which provides training and technical assistance on these interventions, gives CBOs a blueprint for how to implement evidence-based interventions in their communities.

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Assessment Highlights Efficacy of 3MV

A recent assessment of Many Men, Many Voices (3MV) by Jeffrey Herbst and Thomas Painter, both behavioral scientists in DHAP’s Prevention Research Branch (PRB), highlights the intervention’s efficacy.

3MV is a prevention intervention that focuses on black MSM who may or may not identify themselves as gay—and it was the first to focus on that high-risk population. The intervention consists of highly interactive small group sessions that incorporate group exercises, behavioral skills practice, group discussions, and role playing. As part of its “Innovative Interventions” cooperative agreement, PRB funded one of the intervention’s co-developers—the Brooklyn-based People of Color in Crisis, Inc.—to rigorously evaluate the intervention.

The study included 338 black MSM of HIV-negative or unknown HIV serostatus in New York City. Study participants were randomly assigned to the 3MV intervention group (n=164) or to a wait-list comparison group (n=174).

At the 3-month follow-up assessment, 3MV intervention participants reported significantly greater reductions in the number of male sex partners than participants of a wait-list comparison group. When the two groups were compared at 6 months, 3MV participants reported significantly greater reductions in the total number of unprotected anal intercourse episodes; significantly greater reductions in the number of insertive anal intercourse episodes with casual male sex partners; significantly greater rates of HIV testing; and a nearly significant trend for greater increases in consistent condom use during receptive anal intercourse with casual male partners.

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Study to Estimate HIV Incidence among Women from Areas with High HIV Prevalence

DHAP is collaborating with the National Institutes of Health (NIH) and NIH’s HIV Prevention Trials Network (HPTN) on intervention trials that may provide important new information and prevention tools. One of these trials is HPTN 064: The Women’s Seroincidence Study (ISIS), the first HIV incidence study among women living in defined geographic areas in the United States with high HIV prevalence and poverty. ISIS is being conducted by HPTN and funded by the National Institute of Allergy and Infectious Diseases.

Ten U.S. communities (in New York, New Jersey, Maryland, the District of Columbia, North Carolina, and Georgia) were selected for the study. Recruitment has begun in 7 of the 10 communities. Two thousand women will be enrolled in the study and followed for 6 to 12 months.

The primary objective of the study is to estimate the overall HIV-1 incidence rate among women in these defined geographic areas. The study will also evaluate a number of variables, including recruitment and retention; behavioral characteristics; social, structural and cultural factors; barriers to HIV testing among men; and recency (time point of HIV infection) assays. ISIS is part of HPTN’s larger commitment to domestic HIV prevention efforts and to community involvement in research.

A subset of women enrolled in ISIS from four of the communities will also participate in a semi-structured interview or focus group. Men from these same four communities will be recruited to participate in similar focus groups. The qualitative component of ISIS is designed to describe the social and structural context of women’s lives, assess barriers and facilitators to HIV testing among men, and inform future HIV prevention interventions.

The information gained from this study will help inform the design of future, larger-scale trials of promising HIV prevention interventions among women in the United States.

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Only 12.9% of All U.S. High School Students Ever Tested for HIV

Results from the 2007 Youth Risk Behavior Survey (YRBS), a component of CDC’s Youth Risk Behavior Surveillance System, indicate that, nationwide, only 12.9% of high school students have ever been tested for HIV. Adolescents and young adults aged 13–29 years represented 4.4% of the total HIV diagnoses in 2006, but disproportionately comprised an estimated 9.9% of the undiagnosed cases. According to the survey, the prevalence of HIV testing increased with increasing grade level and decreased with increasing age at first sexual intercourse. Female students (14.8%) were more likely than male students (11.1%) to be tested.

Non-Hispanic black students were more likely to be tested (22.4%) than Hispanic (12.7%) and non-Hispanic white (10.7%) students. HIV testing was higher among students who have had sexual intercourse (22.3%) than among those who have never had sexual intercourse (4.0%).

Because two-thirds of adolescents aged 15–17 have had a physical examination in the preceding 12 months, routine testing in health care settings as recommended by CDC could substantially boost testing and awareness of HIV status among high school students. Review the 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings.

YRBS estimates the prevalence of health risk behaviors among high school students through biennial national, state, and local surveys. The 2007 national survey obtained cross-sectional data representative of public- and private-school students in grades 9–12 in the 50 states and the District of Columbia. Read the full report.

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Late HIV Testing Results in Preventable Illness and Death

CDC data released on June 26 indicate that far too many persons in the United States are diagnosed with HIV late in the course of infection, when neither treatment nor prevention can have optimal benefit.

An analysis of persons first diagnosed with HIV from 1996 to 2005 in 34 states with confidential name-based HIV reporting shows that 38.3% received an AIDS diagnosis within 1 year of receiving an initial HIV diagnosis, and an additional 6.7% received an AIDS diagnosis from 1 to 3 years after an HIV diagnosis.

Compared with whites, racial/ethnic minorities were more likely to be diagnosed late; higher percentages of persons of all other racial/ethnic groups progressed to AIDS within 3 years. Those receiving an initial HIV diagnosis at an older age were more likely to progress to AIDS within 3 years, as were men. Because progression from HIV to AIDS generally takes about 10 years without treatment, these findings underscore the importance of HIV testing early in the course of infection, when antiretroviral treatments can have maximum benefit. Additionally, because studies show that most persons who know they are infected take steps to protect their partners, HIV testing is an essential step in reducing the number of new infections.

CDC continues to work on a number of fronts to increase HIV testing and knowledge of serostatus in the United States, both in health care and community settings. Read the full report.

To view other recent MMWR articles with HIV/AIDS content, consultation summaries, and new surveillance reports, fact sheets, and slide sets, check out the What’s New? section on the DHAP Internet.

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New Publications, Web Sites, and Other Materials

Peer-Reviewed Journal Articles

Starting HAART Earlier Suggests Decreased Risk of Antiretroviral Resistance

In “Initiation of HAART at Higher CD4 Cell Counts Is Associated With a Lower Frequency of Antiretroviral Drug Resistance Mutations at Virologic Failure,” published in the Journal of Acquired Immune Deficiency Syndromes (2009;51(4):450–453), Kate Buchacz and John Brooks, both of DHAP’s Epidemiology Branch, and colleagues find that earlier initiation of highly active antiretroviral therapy (HAART) might decrease the risk of developing treatment-limiting antiretroviral resistance.

According to Peter Kilmarx, chief of DHAP’s Epidemiology Branch, the article presents an important new finding because "when to start" treatment to benefit the patient and reduce the risk of transmission is being actively debated.

Article Identifies Challenges and Lessons Learned from Implementing Positive Steps in an Infectious Diseases Clinic

Gary Marks, Christine O’Daniels, and Lytt Gardner, all of EB, and colleagues published “Delivery of an HIV Prevention Counseling Program by HIV Care Providers: Implementation Process and Lessons Learned” in AIDS Patient Care and STDs (2009;23:433–441) about challenges and lessons learned from implementing a provider-delivered HIV transmission risk-reduction intervention for HIV-infected patients (Positive Steps). The intervention was successfully integrated in an infectious diseases clinic and received well by patients.

Once Positive Steps was implemented in the clinic, on average, 69% of patients were screened and 77% of screened patients were counseled during the first 12 months. In analyses of quarterly exit surveys of patients after their medical exams, on average, 73% of respondents reported being asked about safer sex and 51% reported having safer-sex discussions with their providers across six quarterly periods.

Study Examines Acceptability of Vaginal Microbicide Among Women in Chiang Rai, Thailand

Peter H. Kilmarx, chief of the Epidemiology Branch (EB), and colleagues recently published “Acceptability of a Carrageenan-Based Candidate Vaginal Microbicide and Matching Placebo: Findings from a Phase II Safety Trial among Women in Chiang Rai, Thailand” in the Journal of Women’s Health (2009 July 6 [Epub ahead of print).

Of the 165 women enrolled in the study, >87% returned at least 3 used applicators per week. Women in the study generally reported high acceptability and use, but some found 5 mL of gel to be too much. Focusing on enhanced sexual pleasure and lubrication may be beneficial for marketing proven microbicides. Development of products will need to balance lubrication and efficacy with perceptions of too much volume.

In Utero HIV Infections Linked with Increased Risk of NVP Resistance in Infants

Michael Thigpen of EB, Michelle McConnell of the Global AIDS Program (GAP), and colleagues published “In Utero HIV Infection Is Associated with an Increased Risk of Nevirapine Resistance in Ugandan Infants Who Were Exposed to Perinatal Single Dose Nevirapine” in a recent issue of AIDS Research and Human Retroviruses (2009 June 24; [Epub ahead of print]. doi:10.1089/aid.2009.0003).

Their research focused on use of single-dose nevirapine (sdNVP) to prevent mother-infant HIV transmission and infant NVP resistance in Uganda. Combining data from four clinical trials, the authors found that in utero HIV infection was the only factor associated with detection of NVP resistance in infants 6–8 weeks after sdNVP exposure.

Annual Review of HIV Epidemiology Includes Five CDC Authors

Five CDC authors, two from EB (Kilmarx and Van Griensven), two from GAP (Diaz and Sabin), and one from NCHHSTP/OD (Semaan) are featured in the July issue of Current Opinion in HIV and AIDS. Edited by Tim Mastro, formerly of DHAP, and Quarraisha Abdool Karim, the journal’s annual review of HIV epidemiology contains a total of 15 articles. The four articles with CDC authors (in bold) are

• Kilmarx, Peter H. Global epidemiology of HIV. Curr Opin HIV AIDS 2009 July;4(4):240–246.
• Diaz, Theresa; Garcia-Calleja, Jesus M; Ghys, Peter D; Sabin, Keith. Advances and future directions in HIV surveillance in low- and middle-income countries. Curr Opin HIV AIDS 2009 July;4(4):253–259.
• Van Griensven, Frits; de Lind van Wijngaarden, Jan Willem; Baral, Stefan; Grulich, Andrew. The global epidemic of HIV infection among men who have sex with men. Curr Opin HIV AIDS 2009 July:4(4):300–307.
• Des Jarlais, Don C; Arasteh, Kamyar; Semaan, Salaam; Wood, Evan. HIV among injecting drug users: current epidemiology, biologic markers, respondent-driven sampling, and supervised-injection facilities. Curr Opin HIV AIDS 2009 July;4(4):308–313.

Methamphetamine Replacing Cocaine as Drug Most Associated with HIV Seropositivity

Former DHAP staff member Richard Garfein and colleagues recently e-published “Young Adult Injection Drug Users in the United States Continue to Practice HIV Risk Behaviors” ahead of print in the journal Drug and Alcohol Dependence (2009 Jun 24).

In the CDC-funded study, they found that injection and sexual risk behaviors remain common among young injection drug users (IDUs), that racial/ethnic disparities in HIV infection prevalence persist, and that methamphetamine may be replacing cocaine as the drug most associated with HIV seropositivity.

Rapid HIV Testing Acceptable, Feasible, and Faster in Obstetric Outpatient Settings

CDC authors Naomi Tepper, Sherry Farr, Denise Jamieson, Susie Danner (EB), Steve Nesheim (EB), Marc Bulterys (GAP), and co-authors recently published “Rapid Human Immunodeficiency Virus Testing in Obstetric Outpatient Settings: The MIRIAD Study” in the American Journal of Obstetrics & Gynecology (2009;201:31.e1–6). They found that rapid HIV testing was acceptable, feasible, and provides results far sooner than conventional testing in obstetric outpatient settings.

Among eligible women who were offered participation in the study, 90% accepted testing. The median time from blood draw to result available was faster for rapid testing (25 minutes) than conventional testing (23 hours). For rapid tests, point-of-care testing was faster than laboratory-based testing (24 minutes versus 35 minutes). Almost 96% of rapid test results were available within 1 hour.

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Web Site on Social Determinants of Health Resources Is Launched

In June, CDC launched a new Web site to provide links to social determinants of health (SDH) resources.

The Web site was announced upon publication of Addressing Social Determinants of Health: Accelerating the Prevention and Control of HIV/AIDS, Viral Hepatitis, STD, and TB. External Consultation Meeting Report, which presents a summary of the external consultation on SDH held in Atlanta on December 9–10, 2008.

Over time, the site will serve as a comprehensive resource for colleagues and partners; as new information becomes available, the site will continue to expand and new links will be added. Your suggestions on how to improve the SDH Web site are welcomed to ensure that topics important to you are covered. If you have questions about the Addressing Social Determinants of Health report or the SDH Web site, please contact Dr. Kathleen McDavid Harrison at kzm2@cdc.gov.

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Events and Meetings

2009 National HIV Prevention Conference, Atlanta, GA, August 23–26

National Latino AIDS Awareness Day, October 15

National Minority AIDS Council’s U.S. Conference on AIDS, San Francisco, CA, October 29–31

NAPWA World AIDS Day Leadership Conference, Columbus, OH, November 16–17

World AIDS Day, December 1

XVII International AIDS Conference, Vienna, Austria, July 18–23, 2010

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