Public Health Feature - June 2009
Tex Med . 2009;105(6):33-38.
By Crystal Conde
Sitting up, walking, and talking are all normal parts of a baby's growth. For an infant born with HIV, those milestones become more difficult to achieve.
Terence Doran, MD, a pediatric infectious disease specialist with The University of Texas Health Science Center at San Antonio, knows a thing or two about the impact of HIV. He has been caring for HIV-positive infants, children, and adolescents since 1988.
The viral load an HIV-positive infant carries, he says, is much higher than that of an infected adult, causing setbacks in development.
"They get sick faster," he said. "Their viral load stays high for longer periods, and without medication it takes years to come down in children."
Dr. Doran is the medical director of Family Focused AIDS Clinical Treatment Services Clinic, which collaborates with the South Texas Family AIDS Network to serve families affected by HIV and AIDS.
The challenges don't end in infancy. Dr. Doran says that by the time many HIV-infected children reach adolescence, at least one of their parents has died. They may shuffle through various home settings, live in poverty, and turn to alcohol or drugs for comfort. This makes it tough to get them to stay on their lifesaving medications.
These adolescents grow up and take their places among the tens of thousands of Texans living with HIV and AIDS. Data from the Texas Department of State Health Services (DSHS) indicate 62,000 Texans had HIV and AIDS in 2007. Each year, the number of newly reported cases in Texas is about 4,600, while approximately 1,300 Texans die from the diseases annually.
To turn the tide and reduce the effect of HIV and AIDS on all Texans, lawmakers proposed legislation to allow injection drug users (IDUs) to exchange used needles for sterile syringes and to implement opt-out HIV testing of all blood samples taken during routine medical screenings.
Preventing HIV in IDUs
In 2007 alone, DSHS reports 13 percent of new HIV cases stemmed from injection drug use. Other major modes of transmission include male-to-male sexual contact (more than 50 percent) and heterosexual contact (30 percent).
Research supports the use of needle exchange programs to reduce HIV infection among IDUs. The Consensus Panel on HIV Prevention of the National Institutes of Health reports at least a 30-percent reduction of HIV in IDUs through participation in needle exchange programs.
A previous attempt to start a needle exchange program in Texas foundered.
During the 2007 legislative session, Sen. Jane Nelson (R-Lewisville) authored a bill allowing Bexar County to establish a needle exchange program to help reduce communicable diseases such as hepatitis B and HIV.
The needle exchange program never got off the ground because the local district attorney opposed it, and Texas Attorney General Greg Abbott determined the legislation didn't exempt drug users from prosecution for possessing drug paraphernalia.
This year, Sen. Bob Deuell, MD (R-Greenville), and Rep. Ruth McClendon (D-San Antonio) gave passage of needle exchange legislation another shot. Senator Deuell says that misconceptions have prevented the adoption of needle exchange programs.
"Some think that it encourages drug use, as if people are holding off on trying heroin until they can get a clean needle," he said. "Every study I have seen shows the opposite - needle exchange programs often lead addicts into rehabilitation programs."
Senator Deuell and Representative McClendon's legislation (Senate Bill 188 and House Bill 142) allows public health departments and organizations that contract with another entity charged with protecting the public health to establish disease control programs that:
- Provide for the anonymous exchange of used hypodermic needles and syringes for sterile ones;
- Offer education on the transmission and prevention of communicable diseases, including HIV and hepatitis B and C; and
- Help participants obtain health services, including substance abuse treatment and blood-borne disease testing.
Senator Deuell says it's imperative Texas implement these programs, which could conservatively prevent at least 100 cases of HIV within the first year.
The legislation is not a mandate, and Senator Deuell says the state would not bear any of the expense.
"My bill simply gives local governments the option to carry out these programs, as several cities have said they want to do," he said.
The costs associated with these programs would vary, and fees that a local health authority or other entity could charge would partially offset them. The SB 188 fiscal note states possible expenses, including new staff, capital outlay, associated supplies, and operational costs, for fiscal year 2010 would total about $302,600 in Houston, $102,193 in San Antonio, and $106,000 in Conroe.
Senator Deuell says the programs would save the state millions of dollars without costing the legislature a dime. DSHS reports that the average lifetime cost of treating a person with HIV and AIDS is $385,000.
SB 188 and HB 142 have an accountability measure, as well. The bills specify the entity operating the program must provide an annual report on its effectiveness and its impact on reducing drug use and the spread of communicable diseases.
TMA advocates creating HIV education programs that focus on preventing transmission and promoting preventive practices. The association also endorses treatment and education on drug-use cessation and legalizing needle exchange programs.
Although SB 188 passed the Senate and was referred to the House Public Health Committee, the bill's future at press time was uncertain. Gov. Rick Perry's office had spoken out against it.
Making HIV Testing Routine
In 2006, the Centers for Disease Control and Prevention (CDC) updated its recommendations for HIV testing of adults, adolescents, and pregnant women. CDC recommends opt-out HIV screening be part of routine clinical care for patients aged 13 to 64 in all health care settings.
CDC indicates that doing so could decrease the number of new HIV cases by 30 percent annually. According to The Institute for Health Policy at The University of Texas School of Public Health, early HIV diagnosis leads to better treatment outcomes, including slower clinical progression and reduced mortality. TMA supports routine testing that includes an opt-out provision for patients.
Ann Robbins, manager of the DSHS HIV/STD Prevention and Care Branch, says the CDC's recommendation for routine, opt-out testing is an important tool against HIV.
"Studies have shown transmission of HIV is more likely to occur when infected people are unaware of their status, and their viral load is not controlled. Experts estimate that the 20 to 25 percent of persons living with HIV who don't know it account for about half of the new sexually transmitted HIV infections each year," she said.
CDC estimates about one in five people living with HIV don't know they have it.
"We've got a lot of people in Texas living with the disease for years before they're diagnosed. Late diagnosis means more opportunities for transmission of new HIV infections, increased untimely death, and increased health care costs," she said.
Prior to the revised recommendation, CDC advised that patients receive routine HIV testing only in health care settings with high HIV prevalence and on the basis of risky behaviors in environments with low HIV prevalence. Risk-based testing was the norm until the CDC's 2006 revised guidelines. HIV risks changed several times throughout the past two decades but have included activities such as having an HIV-infected partner, being a man who has sex with men, being involved in commercial sex work, having a history of sexually transmitted diseases, and using intravenous drugs.
DSHS reports that only 14 percent of Texans were tested for HIV in 2007. The UT Institute for Health Policy reports that nearly 25 percent of all recently diagnosed individuals in the state are diagnosed with AIDS within one month of finding out they're HIV positive. Statewide, about 33 percent of all newly diagnosed individuals progress to a concurrent AIDS diagnosis within one year of finding out their HIV-positive status.
Dallas County Health and Human Services (DCHHS) Medical Director John Carlo, MD, MSE, realizes that relying on risk-based testing alone can lead to missed opportunities for screening patients for HIV.
"We have to recognize that HIV risk factors aren't being discussed with patients. While we know what the risk factors are, I don't think we adequately get to those risk factors during a clinical patient medical visit," said Dr. Carlo, a member of TMA's Council on Public Health. "Also, we recognize that patients may not choose to disclose to their doctors that they are at high risk for HIV, which is why risk-based testing misses people."
Legislation was filed in this year's legislative session to carry out the CDC's routine HIV screening recommendation at the state level. Sen. Rodney Ellis (D-Houston) is the author of Senate Bill 877 to require testing of all blood samples taken during routine medical screening for HIV unless a patient declines.
SB 877 also addressed insurance barriers by requiring health care payment plans and Medicaid to reimburse for medical tests or procedures to determine infection with any probable causative agent of AIDS, regardless of primary diagnosis. At press time, SB 877 had been referred to the Senate Health & Human Services Committee.
Perinatal HIV Testing in Texas
Texas was an early adopter of routine, opt-out HIV screening in pregnant women in 1996. CDC reports that lack of awareness of HIV status is a major barrier to preventing perinatal HIV transmission.
From 2000 to 2007 in Texas, 7 percent of HIV-positive pregnant women learned of their condition during delivery or after the birth of their children. Thirty-three percent of those women's babies were infected with HIV, compared with 3 percent of babies born to women who knew their HIV status before delivery.
HIV-positive pregnant women can lower their risk of perinatal HIV transmission by receiving antiretroviral therapy (ART) during pregnancy, labor, and delivery; receiving prenatal care; and avoiding breastfeeding. Prophylactic treatment of the infant with ART is a critical component of preventing perinatal HIV transmission, as well.
The Texas Consortium for Perinatal HIV Prevention has proposed new recommendations for perinatal HIV prevention, including conducting the second HIV test in the third trimester, instead of during labor and delivery. (See " Consortium Proposes New Perinatal HIV Prevention Guidelines .")
Alice Gong, MD, a San Antonio neonatologist and chair of TMA's Committee on Maternal and Perinatal Health, says transmission of the disease to infants is greatly reduced when physicians follow the treatment protocol for HIV-positive pregnant women.
"Ensuring HIV-positive pregnant women receive ART medications and appropriate care before, during, and after birth makes a difference in lowering the transmission rate and gives the babies a shot at a better life," she said.
According to DSHS, HIV and AIDS cases due to perinatal transmission fell from 8 percent in 2000 to 1 percent in 2005, but increased to 3 percent in 2006 and 4 percent in 2007. The large decrease in the perinatal transmission rate from 2001 to 2005 highlights the effectiveness of ART in preventing HIV transmission from mother to child. According to DSHS, the increase in the perinatal transmission rate from 2005 to 2007 is difficult to interpret due to the small numbers of cases and needs further investigation.
Throughout the past two decades, Dr. Doran has seen a baby's risk of contracting HIV from an infected mother fall from 25 percent to 1 percent or 2 percent with medical interventions.
Unfortunately, he has detected a small upsurge recently in the number of children coming to the United States from other countries already infected with HIV. And more adolescent girls are contracting HIV, Dr. Doran says, largely due to sexual intercourse with older men.
Expanded efforts to educate the general public about HIV are necessary, he says.
"It's easy to say who's at risk, but most women who are infected have high-risk male partners and are unaware of their activities," he said.
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
HIV: A Texas Snapshot
Appreciating HIV's devastating impact on Texas requires an understanding of whom the disease affects. In Texas, HIV disproportionately affects minorities.
Data available from DSHS for 2007 show African-Americans accounted for 11 percent of the Texas population but made up 38 percent of people living with HIV and AIDS. The rate for whites was 1 in 498, while the rate for African-Americans was 1 in 112 and 1 in 565 for Hispanics.
Statistics from Dallas County Health and Human Services (DCHHS) and DSHS profile new HIV and AIDS diagnoses for 2007. The data indicate African-Americans composed the largest share of new HIV/AIDS diagnoses, at 46 percent, followed by whites (30 percent) and Hispanics (22 percent). But in Dallas County, whites accounted for the largest group already living with the diseases, at 43 percent, followed by African-Americans (39 percent) and Hispanics (17 percent).
John Carlo, MD, MSE, DCHHS medical director, says scientific studies do not adequately explain the reason for higher case numbers in African-Americans. He says the data often point to bigger societal problems such as lack of access to medical care, poverty, and lack of education about HIV risk factors.
In Houston, African-Americans and Hispanics accounted for the largest portion of new HIV and AIDS diagnoses, at 55.4 percent and 25.4 percent, respectively, last year. Whites made up 16.4 percent of new cases.
Data from the Houston Department of Health and Human Services (HDHHS) show African-Americans make up nearly half of the 18,404 people known to be living with HIV this year. Whites make up 27 percent, and Hispanics, 22 percent.
Though the surveillance data are incomplete due to an approximate six-month reporting delay, Beau Mitts, MPH, HIV prevention manager in the HDHHS Bureau of HIV/STD and Viral Hepatitis Prevention, says they are troubling.
HDHHS estimates 3,500 to 4,500 people live with undiagnosed HIV infection in Houston and Harris County. One in 98 Houstonians live with HIV, while 1 in 46 African-Americans in Houston live with the disease. Houston ranks seventh in the nation among cumulative AIDS cases.
And new HIV diagnoses among 13- to 24-year-old men who have sex with men have increased 124 percent since 2001.
To help reduce the impact of HIV on minority populations, CDC awarded HDHHS a $1 million grant in 2007. The department used the funds to expand routine, opt-out HIV testing in three local emergency rooms, one federally qualified health center, and one community-based clinic. Mr. Mitts says the project, which is now in its second year, has been "amazingly successful." So far this year, about 15,000 people have been tested. Of those, 109 have tested positive for HIV.
2006 HIV Rate per 100,000 Population
Dallas County 30.4
Harris County 27.1
Travis County 21.6
Bexar County 14.1
Tarrant County 10.2
Source: Texas Department of State Health Services
Consortium Proposes New Perinatal HIV Prevention Guidelines
Initiated by the Texas Department of State Health Services (DSHS) in 2007, the Texas Consortium for Perinatal HIV Prevention has proposed guidelines for HIV testing of pregnant women and the standards of health care for pregnant, HIV-positive women.
Consortium members include state agencies, community-based organizations, universities, hospitals, private practitioners, and professional associations. The consortium sent the guidelines to physicians, health care professionals, public health experts, and agency and professional organization leaders for feedback. At press time, revised recommendations were being finalized.
The proposed guidelines recommend:
- Conducting the second HIV test in the third trimester, instead of during labor and delivery;
- Having HIV test results available during labor and delivery; and
- Ensuring access to antiretroviral therapy (ART) medications for mothers in labor and their newborn infants.
Sharon K. Melville, MD, MPH, manager of the DSHS TB/HIV/STD Epidemiology and Surveillance Branch, says third-trimester testing would allow more time to plan for treatment and optimal mode of delivery in women found to be HIV positive. The use of ART for mothers during delivery and for their infants after birth, she says, cuts down on the risk of perinatal HIV transmission, as well.
Alice Gong, MD, chair of TMA's Committee on Maternal and Perinatal Health, praises the consortium's guidelines and anticipates they'll be a valuable resource for physicians who care for pregnant women.
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National Campaign Refocuses on HIV Crisis
The White House, the U.S. Department of Health and Human Services, and the Centers for Disease Control and Prevention (CDC) have announced a five-year national communication campaign, the first focused on HIV and AIDS in more than a decade. Act Against AIDS aims to combat complacency about the HIV/AIDS crisis in the United States by putting it back on the nation's radar screen.
CDC reports that every nine-and-a-half minutes another person in America is infected with HIV. According to CDC data released last year, more than 50,000 Americans are newly infected with HIV each year - significantly more than previously known - and more than 14,000 people with AIDS die each year.
"Our goal is to remind Americans that HIV/AIDS continue to pose a serious health threat in the United States and encourage them to get the facts they need to take action for themselves and their communities," said Melody Barnes, assistant to the president and director of the White House Domestic Policy Council.
The campaign will feature public service announcements and online communications, as well as targeted messages and outreach to the populations most severely affected by HIV/AIDS, beginning with African-Americans. Subsequent phases will focus on Latinos and other communities disproportionately affected.
To help achieve widespread use of the campaign messages within African-American communities, the Obama administration also announced the Act Against AIDS Leadership Initiative, a partnership with 14 of the nation's leading African-American civic organizations to integrate HIV prevention into each group's outreach programs.
"Reducing the disproportionate toll of HIV in black communities is one of CDC's top domestic HIV prevention priorities, and African-American leaders have long played an essential role in this fight," said Kevin Fenton, MD, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention.
To promote broad use of the campaign messages, CDC is also collaborating with the Henry J. Kaiser Family Foundation to focus on outreach and technical assistance to the media and the entertainment industry.
The Act Against AIDS campaign will be supported by a CDC budget of roughly $45 million over the next five years, as well as the efforts of community, media, and public health partners across the country to promote and use campaign materials and messages.
The first phase of the Act Against AIDS campaign, called "9½ Minutes," uses a series of video, audio, print, and online materials to increase knowledge about the severity of the HIV/AIDS crisis in the United States.
The next phase will focus on African-Americans. Targeted communications will encourage increased HIV testing among the groups of African-Americans most severely affected - women and gay or bisexual men.
Future phases of the Act Against AIDS campaign will focus on reaching specific populations at greatest risk, including Latinos and other high-risk groups, with HIV prevention messages tailored to meet their unique needs.
For more information about the Act Against AIDS campaign and partner activities, visit www.aids.gov or www.cdc.gov/hiv/aaa . For more information about "9½ Minutes," visit www.nineandahalfminutes.org .
HIV Treatment Interruption High Among Former Inmates
More than 80 percent of HIV-infected inmates released from Texas prisons don't fill their prescriptions within 30 days of their release. A study supported by the National Institute on Drug Abuse, a component of the National Institutes of Health, shows high rates of treatment interruption for HIV, leaving them at heightened risk for poorer health outcomes and an increased risk of transmission of the virus to others.
The Journal of the American Medical Association published the study in its Feb. 25 issue. The study followed all 2,115 HIV-infected inmates who left the Texas State Department of Criminal Justice prison system between January 2004 and December 2007 and were receiving antiretroviral therapy (ART) at the time of their release.
University of Texas researchers found that only 5 percent of those inmates filled a prescription for their ART medication soon enough to avoid a treatment interruption; only 18 percent filled a prescription within 30 days of their release, and only 30 percent did so within 60 days.
Even a small number of ART interruptions can lead to more devastating health outcomes, including an increased risk of premature death and HIV opportunistic infections, such as tuberculosis and hepatitis C. Treatment interruption in combination with resumption of high-risk behaviors may also increase risk for creating reservoirs of drug-resistant HIV in the general community. Because higher viral load predicts greater infectiousness, those who discontinue ART may be more likely to infect their sexual contacts.
Approximately half of all prisoners in the United States have substance abuse problems, which contribute to HIV risk behaviors. HIV-infected inmates leaving prison face immediate social and economic challenges, as well as obstacles to good health care.
As a result, state officials made efforts to encourage these inmates to continue treatment. Upon release, HIV-infected inmates are given a 10-day supply of ART medications, with instructions on how to fill out the necessary forms to receive additional medication at minimal or no cost from state-supported programs, as well as a copy of their most recent lab work and a list of clinicians in their area who provide HIV care.
About half of the inmates across 110 prison sites were also given more formal counseling about how to continue to receive treatment. The study showed that inmates who received the structured assistance were more likely to refill their prescriptions.
In addition, researchers found that inmates released on parole requiring periodic contact with the system were more likely to fill their prescriptions than were those with a standard, unsupervised release. Researchers note that similar support strategies could have broad public health applications across U.S. criminal justice systems.
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