Evolving Role of HIV Biomedical Prevention in Los Angeles County ¡PrEPárate! Summit August 29, 2014 Sonali Kulkarni, MD, MPH Medical Director Division of HIV and STD Programs
ANNUAL DIAGNOSES OF HIV INFECTION 1 , STAGE 3 HIV,PERSONS LIVING WITH HIV AND DEATHS 2 AMONG PERSONS DIAGNOSED WITH HIV INFECTION , LAC 2002-13 2
Percentage of HIV Diagnoses Among Adults/Adolescents By Transmission Category* and Year of Diagnosis, Los Angeles County, 2008-2013 100% 85% 80% 60% 40% 8.6% 20% 3.5% 3% 0% 2008 2009 2010 2011* 2012* MSM IDU MSM/IDU Heterosexual contact * Persons without an identified risk factor are assigned a risk factor using multiple imputation (MI) methods (see technical notes in Annual HIV Surveillance Report). Other risks include hemophilia or coagulation disorder, blood transfusion, perinatal exposure, and confirmed other risks. ** Data are provisional due to reporting delay. 3 Source: HIV Surveillance Report , data as of December 2013.
Percentage of HIV Diagnoses Among Adults/Adolescents By Race/Ethnicity And Year of HIV Diagnosis, Los Angeles County, 2008-2012 60% 50% 49% 40% 30% 23% 21% 20% 10% 5% 1% 0% 2008 2009 2010 2011* 2012* White Black/AA Latino API AI/AN * Data provisional due to reporting delay. 4 Source: HIV Surveillance Report , data as of December 2013.
Comparison of LAC Population with HIV Diagnoses in 2012, by Race/Ethnicity HIV Diagnosed in 2012 LAC Population in 2012 1% 5% 1% 1% White Black 15% 27% 23% Latino Asian/PI 49% 9% AI/AN 21% 48% Other 5 Source: HIV Surveillance Report , data as of December 2013.
HIV Prevalence in MSM, by Race/ Ethnicity – Los Angeles County, NHBS 40 36 35 35 30 27 Black 24 Percent (%) 25 White 19 19 20 15 Latino 16 16 16 10 Asian/PI 6 6 9 5 p=.001 2 p=.06 p<.0001 1 0 2004 2008 2011 1 Significant differences between blacks and Latinos, blacks and APIs and whites and APIs 6 2 Significant differences between blacks and whites, and blacks and APIs
Chlamydia, Gonorrhea and P&S Syphilis Rates, Los Angeles County, 2007-2012 1 600 550 500 450 Rate (per 100,000) 400 350 300 250 200 150 100 50 0 2008 2009 2010 2011 2012 Chlamydia Gonorrhea P&S Syphilis 1 Data are from STD Casewatch; excludes cases in Long Beach and Pasadena; 2010-2012 data are provisional due to reporting delay 7 Source: Division of HIV and STD Programs,
Primary and Secondary Syphilis Rates Among Males, by SPA, LAC, 2008-2012 1 60 55 50 45 40 Rate (per 100,000) 35 30 25 20 15 10 5 0 2008 2009 2010 2011 2012 SPA 1 SPA 2 SPA 3 SPA 4 SPA 5 SPA 6 SPA 7 SPA 8 1 Data are from STD Casewatch as of September 2013; excludes cases in Long Beach and Pasadena; 2012 data are provisional due to reporting delay 8
Evolving Role of Biomedical Prevention • Concept originating with prevention of Mother-to-Child transmission and Occupational Post-exposure Prophylaxis (PEP) • Translated into Non-occupational PEP – Morbidity and Mortality Weekly Report, CDC 2005 • 2011: Definitive data to support Treatment as Prevention – Updated US PHS Treatment Guidelines 2012 • 2012-14: PrEP clinical trials showed reduced risk of HIV infection – Up to 92% lower risk for participants who took medicines consistently than for those who did not take the medicines – CDC’s PrEP Clinical Guidelines 9
CDC’s New PrEP Materials- May 2014 • For Providers • PrEP for Prevention of HIV in the US: Clinical Practice Guideline • Clinical Providers’ Supplement • Provider information sheet- PrEP during conception, pregnancy, and breastfeeding • For Patients • PrEP Information Sheet: PrEP for HIV Prevention (FAQs) • Truvada Medication Information Sheet • Acute HIV: Information about Acute HIV and PrEP Available at: http:www.cdc.gov/hiv/guidelines/preventing.html 10
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CDC Guidance for PrEP Use Men Who Have Sex Heterosexual with Men Women and Men Injection Drug Users • Sex partner with HIV • Sex partner with HIV • HIV positive injecting partner • Recent bacterial STD • Recent bacterial STD • Sharing injection • High # of sex partners • High #of sex partners equipment (6mo) • History of inconsistent • History of inconsistent • Recent drug or no condom use or no condom use treatment (but not • Commercial sex • Commercial sex workers currently injecting) workers • Lives in high-prevalence area or network 1.Centers for Disease Control and Prevention. Pre-exposure Prophylaxis for HIV Prevention brief. May 2014. 14
Key Clinical Considerations Before Starting During PrEP • Documentation of negative • Daily dose of TDF/FTC HIV test before prescribing • <=90 day supply PrEP • Follow-up every 3 mo • No signs or symptoms of – HIV testing q3 mo acute HIV infection – STD testing q6 mo • Normal kidney function, no – Kidney function contraindicated – Side effect assessment medications – Adherence counseling • Documented Hepatitis B – Risk reduction support status and vaccination – Pregnancy testing status – Clean needles/drug tx 15
Access to Biomedical Prevention in LAC DHSP fully supports and endorses use of biomedical interventions as critical components of LAC’s overall HIV prevention strategy. • DHSP actively support for PEP-LA Program and PrEP Demostration Project (CHRP) in Metro and South LA – Currently 8 PrEP demonstration project sites in LAC • Working with Commission on HIV and community planners to incorporate biomedical interventions into our local HIV prevention response – Diversity of access points – Centralized vs. decentralized access points 16
Thank You! Sonali Kulkarni, MD, MPH skulkarni@ph.lacounty.gov Phone: (213) 351 – 8003 http://publichealth.lacounty.gov/dhsp 17
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