This month, Professor Robert L. Cook, MD, MPH received word from recent epidemiology graduate Xingdi Hu, PhD that a manuscript on which they collaborated, with Dr. Hu as lead author, had been accepted for publication. The paper, entitled “Utilization of alcohol treatment among HIV-positive women with hazardous drinking,” will be published by the Journal of Substance Abuse Treatment. In addition to the manuscript reflecting productive associations between epidemiology students and their research mentors, this publication marks Dr. Cook’s 100th peer-reviewed paper accepted for publication. Earlier this year Dr. Cook’s 90th such publication was in collaboration with lead author and recent epidemiology graduate Taj Azarian, PhD. These two mentees, along with yet another recent grad Wajiha Akhtar-Khaleel, PhD, published five collaborative papers with Dr. Cook in the past year.
On Friday, February 19, Dr. Cook gave a seminar with updates on the results of the Florida Cohort entitled, “Does Alcohol and Marijuana Use Correlate with HIV Treatment Engagement and Viral Supression for Persons Living with HIV in Florida?”
Alcohol and marijuana use are common in people living with HIV (PLWH), but it is challenging to identify a “cutpoint” for harmful use. The relationship to the outcomes may vary depending on the mechanism (behavioral or biological). Dr. Cook concluded that there is a need to demonstrate an ability to improve HIV outcomes with substance use intervention.
Ms. Edwards is an HIV/AIDS Peer Navigator at the Florida Department of Health in Alachua County. She was diagnosed in 1987 with HIV and is dedicated to tearing down any stigma associated with HIV. Ms. Edwards also leads the Positives Empowering Positives (PEP) club.
Ms. Koehler-Sides is the Area 3/13 HIV/AIDS Program Coordinator at the Florida Department of Health in Alachua County. Ms. Koehler-Sides is dedicated to helping curb the spread of HIV.
We had a round table discussion about the Peer Navigator program in Area 3/13 and the different strategies used to connect with people. The program aims support HIV-positive individuals as they enter and stay in care, adhere to treatment protocols, and improve their quality of life. We looked at the number of persons living with HIV (PLWH) that were engaged in stages of the continuum of HIV care. About 84% of those diagnosed with HIV in 2014 had documented HIV-related care within 3 months of diagnosis. About 80% in care had a suppressed viral load in 2014.
Recently, more and more courses are shifting away from being taught exclusively in lecture halls or online and instead, professors are turning to the blended learning model, combining the best aspects of both. Material, including recorded lectures and texts, is put up online and students can review them before class. Meanwhile, in class, students work on assignments, allowing them to maximize their interaction with the professor and obtain as much assistance where needed.
In an article in UF Health’s The POST, two SHARC students, Danielle Sharpe (pictured left) and Eugene Dunne, are featured, offering their take on the change.
Read the full article here.
The Deep South region has become the epicenter of the US HIV epidemic. Despite having only 28% of the total US population, nine states in the Deep South account for nearly 40% of national HIV diagnoses. This region has the highest HIV diagnosis rates and the highest number of people living with HIV of any US region based on data for 2008-2011. And new research has found that the five-year survival rate for people diagnosed with HIV or AIDS is lower in the Deep South than in the rest of the country.
So why are we seeing higher death rates and lower survival rates among those living with HIV in the Deep South? The reasons are complicated, but poverty, social stigma, lack of health-care infrastructure and more rural geography likely all play a role.
Five year survival rates are poor
Recent research by the Centers for Disease Control and Prevention (CDC) and the Southern HIV/AIDS Strategy Initiative (SASI) at Duke University Law School in nine states of the Deep South – Alabama, Florida, Georgia, Louisiana, Mississippi and North and South Carolina, Tennessee and Texas – found that people diagnosed with HIV or AIDS in these states are dying at higher rates than those diagnosed in the rest of the country. This is the case even after controlling for regional differences in age, sex, race, and area population size.
CDC/SASI research found that 27% of people diagnosed with AIDS in the Deep South region in 2003-2004 had died within five years of diagnosis. Although five-year survival varied among states in the Deep South, no state had a survival percentage at or above the US average, 77%. In Louisiana, one-third of people diagnosed with AIDS and 19% of those diagnosed with HIV had died within five years of diagnosis.
Researchers also compared the characteristics of those diagnosed with HIV/AIDS in the Deep South region to national averages and found higher percentages of young people (aged 13-24), blacks, females and transmission attributed to heterosexual contact among the region’s individuals diagnosed with HIV. More than one-quarter of people diagnosed with HIV lived outside a large urban area, which is the highest percentage of any US region.
What makes the Deep South different from the rest of the US?
The Deep South has lower levels of income, education and insurance coverage than the rest of the US. Poverty is consistently associated with poorer health so it is not surprising that the Deep
South is experiencing high death rates among those diagnosed with HIV. And none of the Deep South states have accepted federal dollars to expand their Medicaid programs under the Affordable Care Act, leaving thousands of people in the region without health insurance.
Geography also plays a role in the Southern HIV epidemic. Much of the Deep South HIV epidemic is concentrated outside of large urban areas. The CDC/SASI research found that living outside a large urban area at the time of HIV diagnosis significantly predicted greater death rates among people living with HIV in the region.
HIV-related stigma has been found to be higher outside the large urban areas and transportation is a significant barrier to medical care for HIV-positive individuals living outside urban areas since most HIV specialty care is located in urban areas. Without reliable transportation, people miss appointments and may lack access to supportive services such as case management, support groups and legal services.
Thanks to advances in HIV treatment, people who are diagnosed with HIV can have normal life expectancies. But that’s only if they get linked to HIV medical care and remain on treatment, which is a challenge in a region where so many people live outside of urban areas, live in poverty or lack access to health care.
HIV-related stigma has consistently been cited as a driver of the HIV epidemic — especially in the South. In the words of a Deep South focus group participant living with HIV, “HIV doesn’t kill. Stigma kills.”
HIV care providers in the Deep South region tell stories of patients who don’t come to their medical appointments, who won’t participate in support groups, who won’t disclose their HIV status to their closest family members (and the list goes on) because of stigma and a deep fear of how they will be perceived if others discover their status. Stigma also prevents people from getting tested for HIV, which is a critical step in getting the right treatment and in preventing further transmission of the disease.
Overcoming stigma and promoting prevention
The drivers of the Southern HIV epidemic are complicated and to a great extent mirror the causes of poor health outcomes overall in southern states. Creative programs, such as the expansion of telemedicine programs and the co-location of HIV care with other services, such as case management and mental health and substance abuse care, are important to overcome stigma and the lack of transportation and medical care in non-urban areas.
Funding to support anti-stigma interventions, including empowerment initiatives for those living with HIV and educational efforts for churches and community, is critical. Finally, increased prevention funding that is directed at urban and rural areas alike is crucial if we are to stem the new HIV diagnosis rates and lower the death rates in the Deep South.
Susan Reif, Research Associate, Center for Health Policy & Inequalities Research, Duke University and Carolyn McAllaster, Clinical Professor of Law Director, AIDS/HIV and Cancer Legal Project, Duke University
This article was originally published on The Conversation. Read the original article.
Today marks the 15th annual observance of National Black HIV/AIDS Awareness day. HIV/AIDS prevalence is especially high in African Americans, accounting for an estimated 44% of all new HIV infections in 2010.
However, in recent years, research and measures taken in HIV/AIDS prevention and management has made great progress. According to the CDC, black men and women are most likely to report they have been tested for HIV at least once, an important factor in receiving proper care. New HIV infections in African American women decreased for the first time in 2010 (21% decline compared to 2008) and the number of new HIV infections among blacks overall is on target to meet a 2015 national goal to reduce new infections by 25%.
To continue this progress, it is important to get educated, get tested, get involved, and get treated.
The theme for 2015 was “Accelerating Progress: Prevent Infections. Strengthen Care. Reduce Disparities.” The conference emphasized the interactions between prevention and care, the importance of continuing care, and decreasing the disparities in access and outcomes.
During the four-day conference, Dr. Robert Cook presented a poster, “Substance use, mental health symptoms, and HIV viral suppression in the new Florida Cohort,” focusing on the factors associated with detectable HIV viremia among a diverse sample of PLWH in Florida.
From the CDC: The 2015 National HIV Prevention Conference (NHPC) is the preeminent conference for scientists, public health officials, community workers, clinicians, and persons living with HIV from a wide variety of organizations to share their expertise and ultimately prevent infections, strengthen care and reduce disparities. For more information, click here.
It has been almost 35 years since the world was introduced to the term AIDS. In the 1980s, researchers and physicians were trying to understand what was causing waves of strange infections and discovered it was a new virus called the human immunodeficiency virus, or HIV. Since that time, HIV has gone from a death sentence to a manageable chronic disease. Today, it is estimated that 1.2 million people living with HIV in the United States and 50,000 Americans are infected with HIV every year.
Thanks to treatment advances, people with HIV can and do live long and full lives. And that has led to a challenge that doctors and patients in the 1980s and early 1990s may not have imagined: the aging HIV patient. And yet, while we have a treatment regimen that can keep people living with HIV well, and even prevent transmission of the virus, many people, both in the US and overseas, can’t access it.
How did HIV become manageable?
Before 1996, when the first combination drug therapy became available, managing HIV was a burden for patients. The available medications were very highly toxic and didn’t suppress the virus very well. People had to take 4-5 pills every four hours, through the day and night, and endured terrible side effects such as nausea, vomiting and nerve pain. During this time, people living with HIV often advanced to fullblown AIDS and then died.
Then in 1996 it was discovered that a combination of HIV medications could suppress the virus’ replication, or spread, allowing the immune system to recover and fight off other infections like pneumonia. This was a life-changing breakthrough. A patient with HIV can develop AIDS when their immune system is badly damaged, and their body isn’t able to fight infections. Since these new medicines could suppress the virus and prevent immune system damage, they prevented AIDS from developing.
But these drugs still had the same problems that made pre-1996 treatment so tough: a lot of pills, taken all day long. And it was expensive. Initially this kind of treatment was accessible only to people living in developed countries who could afford to pay the high cost of these medicines.
Better treatment and longer lives
Today, people are generally treated with a single, once-a-day, fixed-dose tablet that combines multiple drugs. It is much easier to manage, and has fewer side effects. And the standard of care to suppress the virus is for a patient to begin treatment as soon as possible after diagnosis, and to take it continuously for the rest of his or her life. This strategy also revolutionized how we think about HIV prevention. Five years ago we learned that as soon as patients start taking these medicines and suppresses HIV replication, they are much less likely to transmit HIV to someone else.
In 2012, the US Food and Drug Administration approved the first medication to protect those who do not have HIV from infection, called pre-exposure prophylaxis (PrEP). Today, the Centers for Disease Control and Prevention (CDC) and the World Health Organization recommend PrEP, in combination with behavioral interventions, for populations at high risk of acquiring HIV, such as men who have sex with men and couples where one partner is HIV-infected.
A lifetime of treatment
In the United States today, most people living with HIV can afford medicine, through insurance and programs like the AIDS Drug Assistance Program (a federally funded safety net program providing HIV medications to those underinsured), but these benefits vary widely by state. These medications are redefining what it means to live a healthy life with HIV. Today, people living with HIV are going to college, working, volunteering, getting married and having children. They are not only having children, they also have grandchildren. According to the CDC, one-quarter of people living with HIV in the United States are 55 or older.
Yet even with effective treatment, HIV is now a risk factor for cardiovascular disease, cancer, kidney disease and bone diseases like osteoporosis. That proper treatment can suppress the virus means that we can see the secondary illnesses that HIV can cause. Though the exact reasons why this happens are unknown, it appears a combination of factors – including HIV medication use and increased inflammation from the infection itself – raise risks. And of course, so do health habits such as smoking, substance use, inactivity and a poor diet. That means people with HIV may need to take medication to manage these other conditions in addition to their HIV medication. That means more pills, which can be complicated for patients to manage. And new medications can also cause new side effects. Patients and doctors need to keep an eye out for new symptoms and medication side effects. It takes more than medication for someone with HIV to stay healthy. But the diet and lifestyle changes that can help reduce the risk of chronic disease can be especially tough to manage.
For example, in my research on older adults living with HIV, we found they want to engage in activities that would minimize the risk of these health conditions, like exercise or eating a healthy diet, but that it can be hard to do when balancing their HIV-related self-management work, such as medical and laboratory appointments, tracking symptoms and taking medication. After all, we know these healthy living guidelines are tough even for Americans who aren’t living with HIV to stick to.
But exercise and diet are rarely addressed in HIV primary care visits, missing a great opportunity to evaluate and encourage these behaviors. New work is needed to test strategies to improve and sustain health-promoting behaviors, tailored to the needs of older adults living with HIV. Given the increase in illness and health conditions in this population, the need for these kinds of interventions is urgent.
Excellent treatment is available, but not everyone gets it
The situation is much better in the United States, but there are dramatic disparities in HIV infection prevention, diagnosis and treatment. Here, one in eight Americans living with HIV does not know their HIV status. Without a diagnosis, these people will not get necessary treatment and are more likely to develop AIDS and to spread HIV.
African Americans, Latinos, gay and bisexual men, and transgender people are still bearing a disproportionate burden of this disease in the United States. They are more likely to become HIV-infected and less likely to see a doctor regularly, and, thus, to receive treatment. For example, African Americans comprise 12% of the US population but 44% of all new HIV infections. African Americans are also more likely to die from HIV than other racial groups.
There’s a disparity between men and women as well. Women with HIV have the same health concerns as men with HIV, but they often face additional hurdles in managing their disease and other chronic health conditions due to family responsibilities, trauma and violence, poverty, gynecological issues and childbearing. HIV stigma and shame remain a problem and make it hard for people to manage their condition. Finally, we still lack a cure or vaccine for HIV which would provide the ultimate relief from this disease.
As we remember all of the loved ones we’ve lost to HIV, we should also reflect on how far we’ve come and celebrate that progress. In 2015, the lifespan of a person living with HIV is approximately the same as someone not living with HIV, an impossibility in the early days of the epidemic. But we should also resolve to be part of the generation that stops this virus in all populations. The time to act is now.