Commentary
Why HIV Still Matters in Minnesota
More than 300 new cases are diagnosed each year in the state. Have we become complacent?
By Peter Carr, M.P.H., and Ruth Lynfield, M.D.
Much has changed since the first case of AIDS was reported in Minnesota in 1982. An almost universally fatal infection at the time, HIV is now more medically manageable. Progress also has been made in preventing HIV infection, with notable successes in preventing mother-to-child transmission and transmission among intravenous drug users. Strategies to protect the nation’s blood supply also have been developed.
In spite of these efforts, the number of HIV/AIDS cases reported annually in the United States has increased by 15 percent since 1997, according to the Centers for Disease Control and Prevention. Approximately 300 new cases of HIV have been reported in Minnesota for each of the last 10 years.1 Moreover, the disease has expanded its reach to new populations. Although HIV has been and remains a concern among men who have sex with men, the percentage of new HIV/AIDS cases among females has more than doubled since the early 1990s (from 11 percent of cases in 1990 to 27 percent in 2008). The proportion of cases in youths has increased from 10 percent of cases in 1990 to 16 percent in 2008. In addition, communities of color have continued to experience higher rates of infection and disease than others (eg, the HIV/AIDS rate among African Americans was 10 times greater than the rate among whites in 2008).1
Although HIV is not the epidemic in Minnesota that it is in some parts of the world, it is still a substantial and persistent public health issue. As of the end of 2008, 6,220 persons in the state were known to be living with HIV.1 Treatment advances may have rendered HIV a manageable condition in this country, but the fact that a growing number of people are HIV-positive means that we need stronger, more targeted prevention efforts as well as services to support infected individuals.
One explanation for the steady number of new cases identified in Minnesota each year may be prevention fatigue and complacency. A recent Kaiser Family Foundation survey of public attitudes and opinions found that awareness and the sense of urgency regarding the HIV epidemic in this country is declining.2 This sense of complacency may well be related to progress made in treating HIV infection and the fact that HIV is not having the impact that it did in the early years of the epidemic. Additionally, a substantial number of people in this country still lack accurate information about how HIV is transmitted. Not only do these attitudes and lack of knowledge prevent sexually active persons from doing what they can to prevent transmission of the virus, they may discourage some people from being tested.
During the past five years, 32 percent of Minnesota’s newly diagnosed HIV cases have progressed to AIDS within a year of diagnosis.1 This indicates that these individuals have been unknowingly infected for a number of years. Late diagnoses not only lead to negative health outcomes, they also increase the probability of HIV transmission. The Centers for Disease Control and Prevention recommends routine annual screening of all persons between the ages 13 years and 64 years in order to identify those who may be unknowingly infected.3 However, current screening practices tend to focus on certain high-risk populations and, therefore, miss many individuals who are infected. For that reason, routine HIV screening should be expanded to settings where more people at risk for any sexually transmitted infection are seen such as emergency departments and community clinics in urban areas.
New Approaches to Prevention
Behavioral intervention strategies have been effective in slowing the course of HIV in Minnesota as evidenced by the relatively stable number of new cases seen each year in the face of a steadily increasing reservoir of infection. However, flat funding levels for HIV prevention coupled with prevention fatigue and complacency will make it difficult to sustain these efforts over time.
New approaches to connecting with populations at risk need to be explored. Use of social networking sites such as Facebook and more aggressive use of other communication technologies such as text messaging hold promise as means of delivering HIV-prevention messages. It is important to connect with populations at risk by using the tools that they use to communicate with each other.
In the future, HIV prevention likely will include biomedical interventions. Work continues on developing an HIV vaccine, even though this is proving to be extraordinarily challenging. Microbicides currently under development could be effective in curbing the growing number of heterosexually acquired infections in females.4,5 Circumcision has been shown to be effective in preventing male heterosexual acquisition of HIV.6-8 Clinical trials are underway to assess the effectiveness of using antiretroviral drugs to prevent HIV infection among individuals who have not yet been exposed to the virus.9-11 Although there will be challenges to implementing these interventions, a broad arsenal of prevention tools is needed if we are to decrease the number of new HIV infections.
Also, it is becoming clear that social determinants of health are a powerful force in perpetuating HIV transmission and may, in fact, have a greater impact than behaviors.12,13 Factors such as poverty, racial discrimination, and homophobia influence HIV transmission rates among people in certain sexual networks and among people who inject drugs. Thus, racial segregation and access to health care and education need to be addressed by the public health community as underlying risk factors for HIV transmission.
New Tools for the Fight
The complex web of factors that influence the transmission of HIV make it clear that a wide range of strategies for preventing transmission is necessary if we are to reduce the number of new cases of HIV diagnosed each year. Minnesota and the rest of the country will need to embrace a comprehensive multisector approach to HIV prevention and control similar to that done in parts of the world where the incidence is much greater. To that end, the Minnesota Department of Health is developing HIV prevention, screening, and control strategies that involve the government, health care sector, and community and private entities.
Twenty-seven years after HIV was first recognized in Minnesota, it is still endemic and continues to have a substantial and disproportionate impact on people of color and men who have sex with men. Although great progress has been made in managing HIV, the consequences and costs associated with HIV infections have not diminished. Treatment regimens are lifelong and expensive (the lifetime cost of treating HIV is estimated to be $385,200).14 And the drugs that control the virus often have substantial side effects. We know how to prevent HIV transmission, yet progress in reducing disease rates has stalled over the last decade. Clearly, HIV does still matter and challenges in reducing its incidence (particularly among certain populations) and providing care to people living with HIV remain. Each new generation needs basic HIV education, and older generations need ongoing reminders that HIV is a major public health threat in Minnesota. We cannot let ourselves become complacent about HIV. MM
Peter Carr is the AIDS director and Ruth Lynfield is the state epidemiologist with the Minnesota Department of Health.
The authors would like to thank Roy Nelson and Glenise Johnson, both from the Minnesota Department of Health, for their assistance with this manuscript.
References
1. Minnesota Department of Health. HIV/AIDS Surveillance Report 2008. Available at www.health.state.mn.us/divs/idepc/diseases/hiv/hivsurvrpts.html. Accessed August 31, 2009.
2. Kaiser Family Foundation. 2009 Survey of Americans on HIV/AIDS: Summary of Findings on the Domestic Epidemic. April 2009. Available at: www.kff.org/kaiserpolls/upload/7889.pdf. Accessed August 31,2009.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14): 1-17.
4. Li Q, Estes JD, Schlievert PM, et al. Glycerol monolaurate prevents mucosal SIV transmission. Nature. 2009;458(7241):1034-8.
5. Balzarini J, Van Damme L. Microbicide drug candidates to prevent HIV infection. Lancet. 2007;369(9563):787-97.
6. Auvert B, Taljaard D, Lagarde E, Sobnqwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med. 2005;2(11):e298.
7. Gray, RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007;369(9562):657-66.
8. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007;369 (9562):643-56.
9. Jackson JB, Barnett S, Piwowar-Manning E, et al. A phase I/II study of nevirapine for pre-exposure prophylaxis of HIV-1 transmission in uninfected subjects at high risk. AIDS. 2003;17(4):547-53.
10. Denton PW, Estes JD, Sun Z, et al. Antiretroviral pre-exposure prophylaxis prevents vaginal transmission of HIV-1 in humanized BLT mice. PLoS Med. 2008;5(1):e16.
11. HIV Prevention Trials Network. HPTN 052—A Randomized Trial to Evaluate the Effectiveness of Antiretroviral Therapy Plus HIV Primary Care versus HIV Primary Care Alone to Prevent the Sexual Transmission of HIV-1 in Serodiscordant Couples. Available at: www.hptn.org/research_studies/hptn052.asp. Accessed August 31, 2009.
12. Adimora, A. Schoenbach, V. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. J Infect Dis. 2005;191 (Suppl 1):S115-S122.
13. Centers for Disease Control and Prevention. Addressing Social Determinants of Health: Accelerating the Prevention and Control of HIV/AIDS, Viral Hepatitis, STD and TB. External Consultation Meeting Report. Atlanta, Georgia: Centers for Disease Control and Prevention; April, 2009.
14. Shackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care. 2006;44(11):990-7.