HIV/AIDS and Public Health
Karina Danvers
Director, CT-LPS New England AIDS Education and
Training Center
Yale AIDS Program
Yale School of Medicine
HIV/AIDS
 AIDS (Acquired immune deficiency syndrome or acquired
immunodeficiency syndrome) is a disease caused by a virus called HIV
(Human Immunodeficiency Virus). The illness alters the immune system,
making people much more vulnerable to infections and diseases. This
susceptibility worsens as the disease progresses.
 HIV is found in the body fluids of an infected person (semen and vaginal
fluids, blood and breast milk). The virus is passed from one person to
another through blood-to-blood and sexual contact. In addition, infected
pregnant women can pass HIV to their babies during pregnancy, delivering
the baby during childbirth, and through breast feeding.
 HIV can be transmitted in many ways, such as vaginal, oral sex, anal sex,
blood transfusion, and contaminated hypodermic needles.
 **There is currently no cure for HIV/AIDS.
http://www.nlm.nih.gov/medlineplus/ency/article/000594.htm
Public Health

Public health is "the science and art of preventing disease, prolonging life and promoting health
through the organized efforts and informed choices of society, organizations, public and private,
communities and individuals.

The population in question can be as small as a handful of people, or as large as all the inhabitants
of several continents.

The dimensions of health can encompass "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity", as defined by the United Nations' World
Health Organization. Stigma.

Public health incorporates the interdisciplinary approaches of epidemiology, biostatistics and health
services. Environmental health, community health, behavioral health, health economics, public
policy, insurance medicine and occupational health (respectively occupational medicine) are other
important subfields.

Promotion of hand washing and breastfeeding, delivery of vaccinations, and distribution of
condoms to control the spread of sexually transmitted diseases are examples of common public
health measures.

Modern public health practice requires multidisciplinary teams of professionals including physicians
specializing in public health/community medicine/infectious disease, epidemiologists,
biostatisticians, public health nurses, and others.
Winslow, Charles-Edward Amory (1920 Jan 9). "The Untiltled Fields of Public Health". Science
51 (1306): 23–33.
HIV/AIDS Social Determinants
 “The social determinants of health are “the
circumstances in which people are born, grow up,
live, work and age, and the systems put in place to
deal with illness.”
 Poverty
WHO Commission on the Social Determinants of Health, 2008
Public Health Response in the United States
Macro,Distal
Inter-governmental, Regional,
Global
Society
Community, Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
www.ias.org/2013
The first time we heard GRID? 1980
•
•
•
On June 5, the U.S. Centers for
Disease Control and Prevention (CDC)
publish a Morbidity and Mortality
Weekly Report (MMWR), describing
cases of a rare lung infection,
Pneumocystis carinii pneumonia
(PCP), in five young, previously
healthy, gay men in Los Angeles.
All the men have other unusual
infections as well, indicating that
their immune systems are not
working; two have already died by
the time the report is published.
This edition of the MMWR marks the
first official reporting of what will
become known as the AIDS epidemic.
www.cdc.gov
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
Public Health Response: 1981
• In September,
Congressional
representatives Henry
Waxman and Phillip
Burton introduce
legislation to allocate
$5 million to CDC for
surveillance and $10
million to the National
Institutes of Health
(NIH) for AIDS research.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
Public Health Response: 1983
• The U.S. Centers for Disease
Control and Prevention
(CDC) establish the National
AIDS Hotline to respond to
public inquiries about the
disease.
• On January 4, CDC hosts a
national conference to
determine blood bank
policy blood for testing
blood for HIV, but
participants fail to reach
consensus on appropriate
action.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
PLWA Response: 1983
• In June, people living with
AIDS (PLWAs) take over the
plenary stage at the Second
National AIDS Forum in
Denver, and issue a statement
on the right of PLWAs to be at
the table when policy is made,
to be treated with dignity, and
to be called “people with
AIDS,” not “AIDS victims.”
• The statement becomes
known as “The Denver
Principles,” and it serves as the
charter for the founding of the
National Association of People
with AIDS (NAPWA).
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
Red Ribbon/World AIDS Day
• The Red Ribbon should
be used as a
consciousness raising
symbol -- connection to
blood and the idea of
passion -- not only
anger, but love, like a
valentine.“
• First worn publicly by
Jeremy Irons at the
1991 Tony Awards.
Universal Precautions
•
•
•
The practice was introduced in 1985–88.
In 1987, the practice of universal
precautions was adjusted by a set of rules
known as body substance isolation.
In 1996, both practices were replaced by
the latest approach known as standard
precautions (health care).
Health professionals are instead making
judgments based on an individual's health
status. It is speculated that this differential
approach to care stems from stigma
towards HIV and hepatitis C, rooted
largely in fears and misconceptions
around transmission and assumptions
about patient lifestyle and risk.
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
Bathhouses in San Francisco
•
•
•
•
The San Francisco bathhouse battles of 1984: civil
liberties, AIDS risk, and shifts in health policy.
In the mid-1980s, controversy emerged in a number of
American cities over the roles gay bathhouses and sex
clubs might play in the spread of AIDS, and in raising
safe-sex awareness. In 1984, San Francisco became the
first city where political debates broke out over AIDSrelated policies for bathhouses and sex clubs.
These debates were dominated by questions of public
health and gay civil liberties.
A variety of proposals were put forward during 1984 to
try to reconcile these two concerns, or to give one a
higher priority than the other. Certain officials in San
Francisco's government, and members of its
gay/lesbian/bisexual community, strongly disagreed over
whether the businesses should be closed, should make
their own AIDS-prevention efforts, or should continue
operating under new regulations. Policies implemented
for the city's baths were disconnected from the known
AIDS risk of different sexual behaviors, and from
research findings on AIDS and the local baths. Political
and judicial decisions concerning San Francisco's
bathhouses and sex clubs that were made in 1984 had
continuing influences on these businesses through the
later 1980s and the 1990s.
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
Public Health Response: 1986
• The National Academy of
Sciences issues a report
critical of the U.S. response
to a “national health crisis.”
Macro,
Distal
Inter-governmental,
Regional, Global
Society
• The report calls for a U.S. $2
billion investment.
• An Institute of Medicine
report calls for a national
education campaign and for
creating a National
Commission on AIDS.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
Public Health Response: 1987
 CDC launches the first AIDS-related public service
announcements, “America Responds to AIDS.”
 The America Responds to AIDS campaign presented a
diverse group of people addressing a litany of questions
about AIDS. The questions used an unidentified interviewer
to present these fictional conversations, all of which
involved women in this case, as happening all over
America. The posters did not include any actual information
on prevention or testing, the campaign encouraged a
dialogue about AIDS among peers that diffused some of the
shame and anxiety associated with the disease. In this way,
the campaign combated AIDS by first addressing the fear.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
America Responds to AIDS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1580340/
Needle Exchange 1988
•
In April, the first comprehensive needleexchange program (NEP) in North America is
established in Tacoma, WA. San Francisco
then establishes what becomes the largest
NEP in the nation.
•
State-established Needle Exchange programs
currently operate in California, Colorado,
Connecticut, Illinois, Maryland
Massachusetts, Minnesota, New York, Ohio,
Pennsylvania, Rhode Island, Washington and
Wisconsin. Each of these 13 states has
passed laws exempting program participants
from criminal liability for carrying
hypodermic syringes.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
• So why has it not been possible to
achieve federal funding for such
programs from 1988 to the
present?
•
•
On April 20, Donna Shalala, Secretary of the
U.S. Department of Health and Human
Services, determines that needle-exchange
programs (NEPs) are effective and do not
encourage the use of illegal drugs, but the
Clinton Administration does not lift the ban
on use of Federal funds for NEPs.
The American Medical Association (AMA),
the American Nurses Association, the
American Public Health Association (APHA),
the American Society of Addiction Medicine,
the American Bar Association, and the
Society of Christian Ethics, to name a few, all
endorse needle exchange programs.
First of Its Kind: 1988
• On May 26, the U.S.
Surgeon General, C.
Everett Koop, launches
the U.S.’s first
coordinated HIV/AIDS
education campaign by
mailing 107 million
copies of a booklet,
Understanding AIDS to
all American
households.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Ryan White ACT: 1990
• In August, the U.S. Congress
enacts the Ryan White
Comprehensive AIDS
Resources Emergency (CARE)
Act of 1990, which provides
$220.5 million in Federal funds
for HIV community-based care
and treatment services in its
first year.
• The U.S. Health Resources and
Services Administration (HRSA)
manages the program, which
is the nation’s largest HIVspecific Federal grant program.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
Ryan White
• Ryan Wayne White was
an American teenager
from Kokomo, Indiana,
who became a national
poster child for
HIV/AIDS in the United
States, after being
expelled from middle
school because of his
infection.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Innovations: 1990
• CDC adopts the HIVprevention counseling
model, a “clientcentered” approach
that focuses on the
patient, rather than the
disease.
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Magic Johnson 1991
www.oprahwinfreyshow.com
Interdisciplinary approaches: 1991
• The U.S. Congress enacts
the Housing
Opportunities for People
with AIDS (HOPWA) Act of
1991. Administered by
the U.S. Department of
Housing and Urban
Development (HUD),
HOPWA grants to states
and local communities
provide housing
assistance to people living
with AIDS.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
New Tools: 1993
• On May 7, the U.S.
• Food and Drug
Administration (FDA)
approves the female
condom.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Pregnancy
 The U.S. Public Health Service recommends that
pregnant women be given the antiretroviral drug
AZT to reduce the risk of perinatal transmission
of HIV. (ACTG 076).
 2002: State-mandated HIV testing in Connecticut
for pregnant women.**
 **GYN must offer the test
 **Women may refuse …
 **New born tested after delivery
http://www.aids.gov/pdf/aidsgov-timeline.pdf
Estimated Numbers of Perinatally Acquired AIDS Cases by Year
of Diagnosis, 1985–2010 — United States and Dependent Areas
1,000
No. of cases
800
600
400
200
0
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
Year of diagnosis
8
Note: Data have been adjusted for reporting delays and missing risk-factor information.
www.cdc.gov
Minority Epidemic
 The U.S. Centers for Disease Control and
Prevention (CDC) report that African
Americans account for 49% of U.S. AIDSrelated deaths.
 AIDS-related mortality for African Americans is
almost 10 times that of Whites and three
times that of Hispanics.
http://www.cdc.gov/hiv/risk/racialethnic/aa/
Latinos: 1999
• The Congressional
Hispanic Caucus, with
the Congressional
Hispanic Caucus
Institute , convenes
Congressional hearings
on the impact of
HIV/AIDS on the Latino
community.
http://www.cdc.gov/hiv/risk/racialethnic/aa/
Macro,
Distal
Inter-governmental,
Regional, Global
Society
Community,
Organizations
Relationships, Social
Groups/Networks
Individual
Micro,
Proximal
New HIV Infections: United States
Hispanic Americans
 Hispanic Americans accounted for 20% of all HIV infection
cases in 2011.
 Hispanic males are 3 times as likely to have either HIV
infection or AIDS as compared to white males.
 Hispanic females are 4 times as likely to have AIDS in 2011
as White females.
 Hispanic men are 2.5 times as likely as non-Hispanic White
men to die of HIV/AIDS.
 Hispanic women are twice as likely as non-Hispanic white
women to die of HIV.
 In 2011, Hispanic females were 4 times more likely to be
diagnosed with HIV infection, as compared to White
females.
http://minorityhealth.hhs.gov/templates/content.aspx?ID=3327
CT DPH, Epidemiologic Profile of HIV in CT 2013
CT Public Act No. 09-133 Effective July 1, 2009
 An Act Concerning Revisions to the HIV Testing Consent Law
 Eliminates requirement for separate consent
 Allows general consent for performance of medical procedures
 Eliminates the requirement for extensive pre-test counseling
Courtesy of D. Villanueva, 2013
http://minorityhealth.hhs.gov/templates/content.aspx?ID=3327
Testing Increasing Efforts
http://www.orasure.com/
Adherence
 While the ultimate goal of ART is to reduce HIV-related
morbidity and mortality, the initial goal is full and
durable viral suppression.
 Full viral suppression allows for maximal reconstitution
or maintenance of immune function and minimizes the
emergence of drug-resistant virus selected by ongoing
replication in the presence of antiretroviral drugs.
 Many have viewed nonadherence as a significant
public health concern based on the expectation that
nonadherence would speed the development and
transmission of drug-resistant virus.
HIV InSite Knowledge Base Chapter
May 2005; Content reviewed January 2006
Community Viral Load
 Community viral load, defined as an aggregation of individual viral
loads of people infected with HIV in a specific community, has been
proposed as a useful measure to monitor HIV treatment uptake and
quantify its effect on transmission.
 Lancet Infect Dis. 2013 May;13(5):459-64. doi: 10.1016/S14733099(12)70314-6. Epub 2013 Mar 25.
 In San Francisco, reductions in community viral load have even been
associated with decreases in newly diagnosed and reported HIV
infections. Public health leaders at the CDC and elsewhere are
working to improve the capacity of state and local health
departments to be able to monitor this increasingly useful
population measure. –
 http://blog.aids.gov/2011/03/community-viral-load-a-new-way-to-measureour-progress.html#sthash.U9NHRFVu.dpuf
Functional Cure
 The definition of a "functional HIV cure“ means:




undetectable viremia without ART
no disease progression
no CD4 loss
lack of HIV transmission
 Universal access to cART must remain a top
priority.
 CADAP: CT AIDS Drug Assistance Program
http://iasociety.org/Web/WebContent/File/HIV_Cure_Churchill_Canberra_Presentation.pdf
Medical Interventions: 2006
 In December, a University of Illinois at Chicago
study indicates that medical circumcision of
men reduces their risk of acquiring HIV during
heterosexual intercourse by 53 percent. The
clinical trial of Kenyan men is supported by
the U.S. National Institute for Allergy and
Infectious Diseases and the Canadian Institute
of Health Research.
http://www.aids.gov/pdf/aidsgov-timeline.pdf
HIV Pre-exposure (PrEP)
 PrEP is short for Pre-Exposure Prophylaxis. It is
a new HIV prevention method in which people
who do not have HIV take a daily pill to reduce
their risk of becoming infected.
www.aids.gov
Post-exposure Prophylaxis (PEP)
 Post-exposure prophylaxis is antiretroviral drug
treatment that is started immediately after
someone is exposed to HIV. The aim is to allow a
person’s immune system a chance to provide
protection against the virus and to prevent HIV
from becoming established in someone’s body.
 It usually consists of a month long course of two
or three different types of the antiretroviral drugs
that are also prescribed as treatment for people
living with HIV.
www.aids.gov
Stigma 2013
• Stigma
– Internal
– External
• Partner Services in CT
STD Connecticut Partner
Notification Services
• The State of Connecticut,
Department of Public Health, STD
Control Program attempts to
interview all patients with
syphilis. Some patients with
gonorrhea, Chlamydia, and HIV
are interviewed to assist with
partner notification.
• Patients are educated about their
infection, counseled on how to
avoid re-infection, and asked to
confidentially provide the names
and locating information of their
sexual partners
• Partners are confidentially
located for screening and
treatment by trained field staff
without divulging the identity of
the infected patient.
• MMWR - November 7, 2008 /
Vol. 57/ No. RR-9
• "Recommendations for Partner
Services Programs for HIV
Infection, Syphilis, Gonorrhea,
and Chlamydial Infection”
•
www.ct.gov/dph/cwp/view.asp?a=3136&q=416218
Criminalization of HIV
 Is HIV Criminalization Is Bad Public Policy and Terrible Science?
 CRIMINALIZATION HAS NO EFFECT ON BEHAVIOR & UNDERMINES PUBLIC
HEALTH GOALS
 Studies show that the criminalization of HIV exposure has no effect on risk
behavior.
 HIV criminalization can discourage individuals from seeking testing and
treatment because a positive test result subjects a person to criminal liability
for otherwise non-criminal conduct.
 Health care providers frequently are forced to disclose HIV-related medical
records, including documentation of private communications, as part of a
criminal investigation or trial, interfering with the physician-patient
relationship and the delivery of health services and generating mistrust among
patients.
 Sex between two consenting adults is a shared decision; the responsibility for
protection against disease should not be borne by one partner. Placing
exclusive responsibility on the person living with HIV undermines public health
messages that everyone should take responsibility for individual sexual health.
 Criminalization further stigmatizes an already marginalized population, and
reinforces ignorance and unfounded beliefs about the routes and actual risks
of HIV transmission.
Positive Justice Project, 2013
Early Government Intervention:
Financial Support
Public Health Initiatives
Research
Protection under the Law
Knowledge
Changing/Improving
Social Determinants
Activisms
Prevention Tools
Testing
Medical Prevention Tools
Multidisplinary
Criminalization
Stigma
From here …
“BMS Internal”
HIV/AIDS and Public Health
Karina Danvers
Director, CT-LPS New England AIDS Education and
Training Center
Yale AIDS Program
Yale School of Medicine