VitalSigns November/December Teleconference Transcript: HIV Testing

OPERATOR: Welcome and thank you for standing by. All participants will be on a listen only mode until the question and answer session of today’s call. At that time you may press star, then one, to ask a question from the phone lines. Also this call is being recorded. If you have any objections, you may disconnect at this time. I would now like to turn the call over to your host, Ms. Kathy Harben. Thank you, ma’am, you may begin.

KATHY HARBEN: Thank you, Katie, and thank you all for joining us today for the release of a new CDC Vital Signs. We’re joined by CDC director, Dr. Brenda Fitzgerald, and by Dr. Jonathan Mermin, Director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, and by Dr. Eugene McCray, Director of CDC’s Division of HIV/AIDS Prevention. Drs. Mermin and McCray will respond to questions following our speaker’s remarks. I’ll now turn the call over to Dr. Fitzgerald.

DR. BRENDA FITZGERALD: Good afternoon. Thank you all for joining us today. CDC provides for the common defense of the country for health threats. We protect America’s health, safety, and security by responding to our nation’s most pressing health threats. In each Vital Signs Report, we focus on one of these threats and what we’re doing about it. Today’s Vital Signs Report has new information about HIV testing and diagnosis in the United States. And overall it reveals that we as a nation are making great progress in HIV prevention. People at risk for HIV are getting tested more frequently and HIV is being diagnosed sooner after infections. Annual HIV infections are down. A higher proportion of all people living well HIV have gotten diagnosed. And more people with HIV have the virus under control through treatment. These are all very encouraging signs and are a testament to the thousands of people working every day to lessen the toll HIV takes on the American community. Yet despite this progress, today’s report also highlights ongoing challenges. For example, many Americans aren’t getting tested for HIV as CDC recommends. And too many people have HIV infections that go undiagnosed for far too long. CDC’s testing efforts identify more than 12,000 people with HIV each year and account for one third of all HIV diagnoses in the United States. We know that an HIV test opens doors to care, treatment, and prevention. Once diagnosed, HIV can be treated so that people who have HIV can live long, healthy lives. Treating HIV is also a powerful tool for preventing the sexual transmission of HIV. We also know that we are still missing opportunities to test many people who are most at risk for HIV. So while we should celebrate our progress, we must still make HIV prevention a priority. This is an epidemic we can stop. So let’s pledge to work together and end it forever. Now I turn it over to Dr. Jonathan Mermin and Dr. Eugene McCray for a more detailed look at this Vital Signs Report.

DR. JONATHAN MERMIN: Thank you, Dr. Fitzgerald. And thank you all for joining us to focus on this important issue. Testing for HIV is central to addressing HIV in this country, because prompt diagnosis is prevention. A positive HIV test allows people living with HIV to start treatment that will help them live longer, healthier lives, and get the virus under control. Controlling HIV through treatment called viral suppression is a top national priority. And among people who have achieved viral suppression, HIV is detectable only at very low levels in the blood or is undetectable with standard tests. In recent studies of thousands of couples where one partner has HIV and the other does not, there have been no sexually transmitted HIV infections when the HIV-positive partner was virally suppressed. Testing also opens the door to prevention options for people who do not have HIV but who are at risk for infection. It’s true, HIV testing works. If you think you’re at risk, don’t guess, get the test. CDC recommends all people aged 13-64 be tested for HIV at least once in their lifetime and people at higher risk for HIV at least annually. Health care providers may also find it beneficial to test some people more frequently than that. For this Vital Signs, we analyzed data from CDC’s National HIV Behavioral Surveillance System to understand HIV testing rates among people at particularly high risk for HIV, including gay and bisexual men, people who inject drugs, and heterosexuals at increased risk for HIV. Although HIV testing is up among these risk groups, our report also found we still need to test more people and test more often. According to this Vital Signs Report, those reporting they did not have a recent HIV test were almost one-third in gay and bisexual men, more than two in five people who inject drugs, and more than one in two heterosexuals at risk for HIV. The Vital Signs Report also found seven in ten people at high risk who were not tested for HIV in the past year saw a health care provider during that time, signaling a missed opportunity for high risk individuals to be tested as frequently as needed. Without increased testing, many people living with HIV may not know they have it for years, and this report suggests that far too many people live with HIV for far too long before receiving a diagnosis. The Vital Signs analysis found a quarter of people whose HIV was diagnosed in 2015 had lived with HIV for seven years or more without knowing they had it. For this Vital Signs Report, we also analyzed national HIV surveillance data to estimate timing from HIV infection to diagnosis. In other words, we wanted to understand how long people live with HIV without knowing they have the virus. We found that the estimated median time from HIV infection to diagnosis was three years in 2015, meaning that half of people diagnosed with HIV in 2015 had been living with HIV for three years or more without knowing it. That’s an improvement from 2011 when the estimated median time from HIV infection to detection was three years and seven months. The report also tells us that some groups, particularly heterosexual men and racial and ethnic minorities, live with HIV for longer than other groups before they are diagnosed. For example, in 2015, estimated timing from HIV infection to diagnosis for heterosexual men was a median of five years, twice as long as heterosexual women. The median was three years for gay and bisexual men. Estimated timing from HIV infection to diagnosis ranged from a median of four years for Asian-Americans to two years for White Americans. The median was about three years for African-Americans and Latinos. So now I’m going to turn the microphone over to Dr. Eugene McCray who will discuss specific aspects of CDC’s HIV programs.

DR. EUGENE MCCRAY: Thank you, Dr. Mermin. About 40 percent of new HIV infections in this country are from people who don’t know they have HIV. So we must close the gap in time from HIV infection to HIV diagnosis to end our nation’s epidemic. CDC is working to make this happen by doing several things. Educating the public and health care providers about the importance of testing, prevention, and treatment. Funding health departments and community-based organizations to conduct HIV testing programs. And developing new testing recommendations to help diagnose HIV earlier, when people are most likely to transmit the virus. Health care providers can do their part by testing more people for HIV as part of routine medical care, and testing those at increased risk more frequently and linking those who receive a positive test results to care. Health departments and community based organizations can also test people for HIV or create programs that increase HIV testing in populations at greater risk. And they can help educate communities about the benefits of testing, early diagnosis, and treatment for those who are living with HIV. And finally, every American can play a role by getting tested at least once and people at high risk for HIV getting tested every year. HIV testing works. Getting more HIV infections diagnosed and more people living with HIV on treatment is crucial to driving down the disease. Thank you. I’ll turn it back over to our moderator now.

KATHY HARBEN: Thank you, Dr. McCray. I believe we are ready for questions.

OPERATOR: Thank you. At this time we would like to begin the question and answer session of today’s conference. If you would like to ask a question from the phone lines, please press star, then one, unmute your phone, and record your name when prompted. If you need to withdraw your question, please press star, then two. Once again, to ask a question from the phone lines, please press star, then one, and record your name when prompted. Our first question comes from Eben Brown. Your line is now open.

EBEN BROWN: Thank you very much. Nice to meet you, Dr. Fitzgerald. I’m one of the people who often calls into these teleconferences, although I’m not located in Atlanta, so I don’t get to visit the CDC much. You made a very interesting comment at the top, saying that HIV would be in your words just a few moments ago, beatable. And I’m just thinking back, you know, 20 years, 30 years, how that really wasn’t the attitude then, that this was really considered a plague and there was a great amount of shame associated with it. Could you reflect for a bit, now as you’re head of the CDC, to just talk about how different of an atmosphere there is and how much hope there is now for people with HIV and that, you know, with testing, treatment obviously would follow, and how it’s so not the death sentence it used to be?

KATHY HARBEN: Eben, this is Kathy Harben. Dr. Fitzgerald has dropped off the call.

EBEN BROWN: Oh, okay. Well, if anyone would like to make such comments that would be great.

DR. JONATHAN MERMIN: Sure, thanks. For those of us who have been working in HIV for many decades, it’s actually an encouraging time and a challenging time. Maybe Dr. McCray would also have some thoughts. I would say there’s more encouraging signs in a decade marked by progress in HIV prevention. We’ve seen reductions in HIV incidence, meaning the number of new infections every year in the country, over the past decade. And we’ve seen dramatic reductions in mortality among people with HIV due to very effective medicine that can now be taken once a day in most cases. And we’ve also seen impressive improvements in HIV prevention, including pre-exposure prophylaxis, which is when one takes a pill a day to prevent acquisition of HIV and acknowledging the prevention effects of antiretroviral therapy in reducing viral load. All of these things have come together to provide more opportunities for people who do have HIV and I think have led people to understand that there’s more hope than there was in the past. At the same time, there continue to be major challenges. We have close to 40,000 new HIV infections every year. HIV is often a fatal disease if it is not treated. And it continues to be a challenge to reduce the number of new infections every year. Eugene, did you want to add anything?

DR. EUGENE MCCRAY: No, just to add that we have the tools that we need to really continue to see significant progress in HIV infection in the U.S. and the challenges, as Dr. Mermin is saying, getting those tools to the people who need them the most, such as young people, certain high risk populations, and then in certain geographic areas.

EBEN BROWN: Thank you.

KATHY HARBEN: Next question, please.

OPERATOR: Our next question comes from Julie Steenhuysen from Reuters. Your line is now open.

JULIE STEENHUYSEN: Thanks for taking my call. Dr. Mermin, I just would like to press a little further to understand the improvements you’ve seen in people at high risk of HIV infection. It looks like particularly with racial minorities and heterosexual men, the rates of diagnosis or the time it takes to be diagnosed is still quite long. Have you seen progress in that group and what is CDC doing to particularly address, you know, lack of testing among these at-risk populations?

DR. JONATHAN MERMIN: So HIV is a quintessential example of disparities in public health. Since its inception or since its discovery, we’ve continued to see certain populations most affected by HIV and they can be racial and ethnic groups. For example, African-Americans are eight times more likely and Latinos are ten times more likely to have HIV infections than White Americans. It can be geographically distributed. The southern part of the United States has higher HIV burden than any other region. And certain age groups and sexes, as well as, gay and bisexual men. So we have seen these disparities. And we’ve worked specifically to try to reduce them while we also reduce HIV infections in the nation as a whole. And I should say, we have seen some progress, including an 18 percent reduction in new infections over the past decade. What we’ve also seen is persistent disparities. There have been some places we’ve been able to make inroads. One example is the HIV testing that CDC supports through state and local health departments. In one program, where we focused testing in the most hard-hit areas, we diagnosed over 10,000 new people with HIV infection, 70 percent were African-American, 12 percent were Latino. We also did an economic analysis and showed that for every dollar spent, a minimum of $2 was saved by the health care system through that testing program. So HIV, good HIV prevention saves lives and saves money. You raised specifically the question about kind of reductions in time to diagnosis in certain groups.

JULIE STEENHUYSEN: Yes.

DR. JONATHAN MERMIN: There is a persistent disparity in that. We have seen reductions overall and in these specific groups. But the differences between those groups do continue. And we have to work hard to reduce them. To some extent, we are ensconced in the health care environment that people live in. So for example, why are women diagnosed sooner than men? Women are more comfortable and more frequently go to the health care system. Women are often screened for HIV when they’re pregnant, that’s part national guidelines. So you can imagine, women are experiencing HIV testing more frequently than men and therefore the time from infection to diagnosis would be less. But we are seeing for heterosexual men in particular a longer time frame to getting diagnosis. It’s something that we have to work on. We have two pillars of our approach. One is the routine recommendation of HIV screening, you know, once in one’s lifetime. And that would catch people who might not have thought themselves at risk or the clinician might not have thought of them at risk. And then we have people where we recommend a more frequently testing of at least once a year, because once in a lifetime isn’t enough, and that would allow a more rapid diagnosis. Primarily because prompt diagnosis is prevention.

KATHY HARBEN: Next question, please.

OPERATOR: Our next question comes from Betsy McKay from Wall Street Journal. Your line is now open.

BETSY MCKAY: Hi, thanks, I had a couple of questions. One is, what are some of the more successful ways or means in which, you know, tests are being made available to people, particularly those who don’t really come often to the health care system? I’m just curious what innovations there are out there that have been tried and seem to work in getting more people tested. And then the second question was how do you measure time from infection to a positive test? You know, the three years, the median of three years that you were talking about.

DR. JONATHAN MERMIN: So Betsy, I’ll start with the second question, then I’ll turn it over to Dr. McCray to cover the first part. But when someone is infected with HIV, over time their immune function decreases. And we measure that in general — [inaudible interference]

KATHY HARBEN: If you’re not talking, please mute.

DR. JONATHAN MERMIN: Thanks. So what happens is, we use a model that incorporates that decline in CD4 counts. We know that CD4 counts are measured when someone is newly diagnosed with HIV because it’s beneficial to their health because there are certain medicine we provide to people to prevent infections depending on how much higher their CD4 count is. So essentially that’s reported. We use that CD4 count to estimate how much time from infection to diagnosis there was for people and then we apply that in the model. So essentially it’s assuming a slow decline, whatever the natural decline in CD4 count over time. Eugene, did you want to touch base on the first one?

DR. EUGENE MCCRAY: Yes, so the question was I think was how do you reach people who are not getting tested and what are some of the strategies that are being used to identifying and getting those hard to reach populations tested. One of the things Dr. Mermin mentioned earlier in his briefing is that we have targeted testing initiatives where we actually do targeted testing to communities where we know there is a high prevalence of HIV, people living with HIV, and where there are people that are at high risk for HIV. So for example, young African-American MSM, men having sex with men, we can target those. We also do what we call event-based testing, when there are specific events like gay prides and special events where we have large groups of people that are at a high risk coming together, we can do testing in those venues. And other innovative approaches that are being used is having walk-in clinics where individuals can come in, if they’re concerned that they may be at risk for HIV or have been exposed, they can do self-testing, where they come in, give a history, do a swab, and then that swab or urine can get evaluated and tested within hours, and then they can be given a result. That’s for sexually transmitted infections also, they can come in and request testing for HIV. So we’re having to try a number of different venues. A major part of what we’re doing also is trying to have specific communication campaigns that are targeting people at risk groups or hard to reach groups so that they know where they can get a test and get it safely without any problems.

DR. JONATHAN MERMIN: And just to add, there is also creative programs involving either over the counter HIV tests that people can purchase or be provided and then test themselves at home, and even provision of test through the internet, so people can receive — essentially order and receive a test through the internet. I would also say that hard to reach populations you can reach by kind of on the ground work with people who are at high risk for HIV. You can also reach them by having screening become routine in health care settings. So if someone goes to the emergency department or does go to their primary care practitioner, it’s as routine as a cholesterol check. And we don’t burden people having to think about themselves potentially at risk for HIV because the system itself makes the healthy choice and easy choice. It offers that test and people can get tested because it’s what is recommended through practitioner guidelines.

KATHY HARBEN: Next question, please.

OPERATOR: Our next question comes from Maggie Fox with NBC News. Your line is now open.

MAGGIE FOX: Thanks very much, I’m sorry if I missed this earlier, but can you talk about the percentage of new infections that are coming from people who evidently did not know they were HIV-positive and how you figure that out?

DR. JONATHAN MERMIN: It’s 40 percent, we estimate that 40 percent of HIV infections in the United States are inadvertently or unknowingly being transmitted by persons who don’t know that they have HIV. And we calculate that through a mathematical model that also incorporates viral load and antiretroviral therapy and behavior among the populations with HIV in the United States. And we have a paper that we can share.

MAGGIE FOX: Thank you.

DR. JONATHAN MERMIN: Next question?

OPERATOR: Our next question comes from Gracie Bond-Staples with the Atlanta Journal Constitution. Your line is now open.

GRACIE BONDS-STAPLES: As you know, metro Atlanta has been for a long time in the thick of this epidemic. I’m wondering if you can address the rates of infection here in the south and particularly in metro Atlanta, and if you hold out any hope for this particular area of the south, in terms of beating the epidemic.

DR. JONATHAN MERMIN: So I think there are two aspects to the response to your question. The first is that yes, there is hope. The state of Georgia saw a 25 percent reduction in new HIV infections over the past — over the period of time between 2008 and 2014. So we can — we know that if we do what we know is effective and get it implemented, we can make a difference. At the same time, the Atlanta region and other parts of the state are disproportionately affected by HIV and that there are disparities even within the city of Atlanta. There are populations at very high risk of HIV that are hard to reach or have seen some reductions, but not at the scale that we would need. And I don’t know if, Eugene, you wanted to talk about specific activities in Atlanta or Georgia or what you think needs to be done.

DR. EUGENE MCCRAY: Yeah, no, I mean I think you covered some of what’s going on. But what some of the specific things that are being done or actually — we’re working very closely with the State of Georgia and specifically with Fulton County in facilitating more collaborations with academia to help really better identify where the infections are and make sure that we’re following what we call a high impact intervention approach in targeting our resources to the area that’s most impacted. That’s work that’s ongoing and I think we’re going to see — we are going to be seeing good results from that as we move forward. For example, Fulton County, we’ll be collaborating very closely with Emory University and the Center for AIDS Research as we move forward to really begin tackling at least the epidemic in the Fulton county area. And I would like to mention that, you know, the epidemic in Georgia is still primarily an urban epidemic, close to 70 percent of the cases are in the metro Atlanta area.

DR. JONATHAN MERMIN: So I am hopeful for the nation and the south. But it will require thoughtful concerted action with what we know works, because good HIV prevention saves lives and saves money.

GRACIE BONDS-STAPLES: Thank you.

DR. JONATHAN MERMIN: Thank you. Next question?

OPERATOR: Our next question comes from Lisa Hagen with WABE. Your line is now open.

LISA HAGEN: Hi there. I was wondering, so I’m also out of Atlanta, and I’m wondering, you know, if there are any examples of cities with roughly the same, you know, population or socioeconomic characteristics like Atlanta that you have seen actually have a turnaround that you would consider successful, and how we might get to that place.

DR. JONATHAN MERMIN: I think those of us who live in Atlanta think we are unique and special. But I would say that there are large cities that, like Atlanta, have seen some progress. Washington, D.C. has had dramatic reductions in HIV incidence over the past few years. And other cities like New York City, San Francisco, L.A., have all been able to achieve progress, as well as some other cities in the south. But they’re starting, many cities in the south are starting with much higher rates. And so it’s going to take more work, it’s going to take more concerted work, and it’s going to take reaching the people who really need the services that are going to make a big difference.

KATHY HARBEN: Next question, please.

OPERATOR: Once again, if you would like to ask a question from the phone lines, please press star, then one. Unmute your phone and record your name and prompted. We are currently showing no questions at this time.

KATHY HARBEN: Okay. Thanks, everyone. I would like to thank Dr. Fitzgerald, Dr. Mermin, and Dr. McCray for joining us today. If media have follow-up questions, you can reach us at 404-639-3286, or send an e-mail to media@cdc.gov. Thank you for joining us. This concludes our call.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES