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Pacific AETC has developed the Expand Your HIV Toolkit: Cabotegravir and Rilpivirine (CAB/RPV) Essentials and Clinical Guide to inform healthcare providers about CAB/RPV, the first FDA-approved long-acting injectable antiretroviral (ARV) medication for patients with HIV. This comprehensive toolkit includes:

• Recommendations for patient evaluation, screening, and shared decision making when considering prescribing CAB/RPV.
• Implementation tools such as sample checklists, protocols, and resources available to aid in the implementation of offering CAB/RVP in healthcare settings.  

Click here to access the toolkit

The toolkit was developed to enhance the content of a 4-part webinar series held January – April, 2022, titled: Expand your HIV Toolkit: CA Statewide Trainings on Extended-Release Injectable Suspensions for HIV Treatment and Prevention.  The series was designed to equip California clinicians, pharmacists, and members of the healthcare team with an in-depth understanding of Cabotegravir/Rilpivirine (Cabenuva). Attendees gained:

• Real-world patient and provider perspectives.
• A guide to patient eligibility, clinical considerations, and insurance coverage.
• Insights to increase equitable access for priority populations. 

Register below to watch the 4-part series and access materials.

Watch the Series Now

More than 160,000 Americans are unaware they are living with HIV. Diagnosing HIV is critical to the success of the Ending the HIV Epidemic in America initiative (EHE). How can we assist clinical providers in identifying individuals who would not otherwise receive HIV testing? Research demonstrates large-scale HIV screening in the emergency departments and urgent care settings using existing staff and resources, regardless of patient selection strategy, does not impact care processes or patient flow.

Join the Denver PTC on Wednesday December 14, 2022 as they deliver a webinar on HIV Testing in Emergency Rooms – A Public Health Initiative to Improve Early HIV Detection and Linkage to Care.

No registration is required. Access the Zoom information below:

Zoom Link Here

(https://umsystem.zoom.us/j/%206962103759?pwd=MmxMbHUweUtkZkRPb2w4c0QrV1Jhdz09)

Meeting ID: 696 210 3759

Passcode: 123321

Learn how your team can maximize opt-out HIV screening!

Cross-posted from NIAID Newsroom

Starting antiretroviral treatment (ART) early in the course of HIV infection when the immune system is stronger results in better long-term health outcomes compared with delaying ART, according to findings presented at the IDWeek Conference in Washington, D.C.

The findings are based on an extended follow-up of participants in the National Institutes of Health-funded Strategic Timing of Antiretroviral Treatment (START) study. In 2015, START demonstrated a 57% reduced risk of AIDS and serious non-AIDS health outcomes among participants who began ART when their CD4+ T-cell counts—a key indicator of immune system health—were greater than 500 cells per cubic millimeter (mm³) compared with those who did not begin ART until either their CD4+ counts fell below 350 cells/mm³ or they developed AIDS. Following the 2015 report of these findings, the participants in the deferred treatment arm were advised to begin ART.

Approximately, 1.2 million people in the United States are living with HIV, and roughly 13% do not know they are infected, according to the Centers for Disease Control and Prevention. When HIV diagnosis and treatment are delayed, HIV continues to replicate. This can negatively impact the infected individual’s health and increase the risk of transmitting the virus to others.

The international START study proved the benefit of early ART initiation, but longer-term follow-up of 4,446 participants was undertaken to determine whether the health benefits of early ART compared with deferred ART increased, remained constant, or declined after the participants in the deferred arm were advised to begin ART. The primary study endpoints included the number of participants who developed AIDS; those who developed serious non-AIDS health conditions, such as major cardiovascular disease, kidney failure, liver disease and cancer; and those who died.

For participants who began ART before the end of 2015, the median CD4+ cell count at the time of ART initiation was 648 cells/mm³ for the immediate arm and 460 cells/mm³ for the deferred arm. The analysis presented [on 10/21/22] compared the primary study endpoints before the end of 2015, with those in the extended follow-up period, from Jan. 1, 2016, to Dec. 31, 2021. In the latter period, most deferred-arm participants were taking ART. During the second period, people initiating ART in the deferred group had rapid and sustained declines in HIV viral load (less than or equal to 200 copies/mL); however, CD4+ cell counts remained, on average, 155 cells lower compared with that of individuals in the immediate ART group. While the risk of serious health outcomes was substantially diminished soon after ART was initiated in the deferred treatment group, some excess risk remained compared with the immediate treatment group. The deferred ART group continued to have a somewhat greater risk (21%) of serious health consequences or death in comparison to the immediate treatment group. Twenty-seven cases of AIDS occurred in the five-year follow-up period in the deferred treatment group compared with 15 cases in the early treatment group. Similarly, 88 cases of serious non-AIDS health issues occurred in the deferred treatment arm compared with 76 cases in the immediate treatment arm. Lastly, there were 57 deaths in the deferred treatment group compared to 47 in the immediate treatment arm.

These findings confirm that ART significantly improves the health of an individual with HIV and reduce the person’s risk of developing AIDS and serious health issues, and that early diagnosis and treatment are key to maximizing these benefits and reducing risk, according to the presenters.

The START study and its extended follow up was conducted by the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT), funded in part by the National Institute of Allergy and Infectious Diseases (NIAID), part of NIH. It was led by principal investigator James D. Neaton, Ph.D., of the University of Minnesota, Minneapolis, and START study co-chairs Abdel Babiker, Ph.D., of the University College London, and Jens Lundgren, M.D., of the University of Copenhagen.

Cross-posted from HIV.gov

New CDC MMWR Articles: Increasing Equity in Monkeypox Vaccine Distribution

Last Friday, CDC published three new Morbidity and Mortality Weekly Report (MMWR) reports on recent developments in monkeypox vaccination in the U.S.:

• Receipt of First and Second Doses of JYNNEOS Vaccine for Prevention of Monkeypox — United States, May 22–October 10, 2022
• Characteristics of JYNNEOS Vaccine Recipients Before and During a Large Multiday LGBTQIA+ Festival — Louisiana, August 9–September 5, 2022
• A Health Equity Approach for Implementation of JYNNEOS Vaccination at Large, Community-Based LGBTQIA+ Events — Georgia, August 27–September 5, 2022

The first report shows that progress has been made in increasing the proportion of Black and Hispanic persons vaccinated against monkeypox virus in the U.S. According to the report, by October 10, 2022, 931,155 JYNNEOS vaccine doses were administered in the United States. Among persons who received ≥1 vaccine dose, 51.4% were non-Hispanic White, 12.6% were non-Hispanic Black or African American (Black), and 22.5% were Hispanic persons. The percentages of vaccine recipients who were Black (5.6%) and Hispanic (15.5%) during May 22–June 25 increased to 13.3% and 22.7%, respectively, during July 31–October 10. The Importance of Community Vaccination Events The other reports detail how community vaccination events can help make access to vaccines easier for people most affected by monkeypox. This summer’s Southern Decadence event in Louisiana and the Atlanta Black Gay Pride Festival in Georgia are highlighted. Both events provided the opportunity to increase access to monkeypox vaccination among populations disproportionally affected by the monkeypox outbreak. Community engagement, targeted messaging, and selection of venues catering primarily to racial and ethnic minorities for community vaccination events improved vaccine equity and reduced health disparities. For the latest information on monkeypox in the U.S., visit CDC.gov.

Addressing Monkeypox Holistically

From day one of the Biden Administration’s response to the Monkeypox outbreak, we have recognized that Monkeypox is not a virus that lives in isolation. It exists as a part of a number of acute and chronic outbreaks and health challenges that interact with each other and can be impacted by social circumstances that worsen disease outcomes. Such interacting epidemics, or “syndemics,” require responses beyond traditional disease-specific healthcare delivery and to also address associated social determinants of health. That’s why we have worked closely—and successfully—within the Administration and with our partners in public health, the LGBTQI+ community, and with community-based organizations—to combat and treat this virus using a holistic approach, that takes all of these factors into consideration.

HIV and Monkeypox are examples of syndemic outbreaks that interact with each other and therefore require specific action for both diseases in order to mitigate the impact of both. Recent epidemiology has shown that people with HIV continue to be over-represented in cases and severe manifestations of Monkeypox disease. In one study published by the CDC, nearly 40% of people diagnosed with Monkeypox had HIV infection, and over 40% had been diagnosed with a sexually transmitted infection (STI) in the year prior to their Monkeypox diagnosis.¹

In an even more recent study of 57 people reported to CDC with severe Monkeypox infections, 82% had advanced HIV infection and nearly three-quarters of these individuals had very compromised immune systems with extremely low CD4 cell counts. Under 9% of these patients were taking antiretrovirals at the time of their Monkeypox diagnosis. Some people succumbed to these preventable infections.²

Syndemics are not just about viruses and bacteria; social circumstances like systemic inequities in the health care system and social determinants of health like housing interact with infections to worsen or deepen their impact. In this same report of severe Monkeypox outcomes, nearly 70% of patients were Black and 23% were experiencing homelessness.²

These statistics make it clear the need to continue an aggressive and comprehensive approach to address Monkeypox, HIV, STIs, homelessness, and mental health together. HIV prevention and care mitigates the impact of Monkeypox on the health of individuals living with or at-risk for both infections. And, linkage to HIV care and treatment is critical to protect individuals from a variety of health threats, including Monkeypox.

Throughout our response to the Monkeypox outbreak, the Biden-Harris Administration has taken critical actions toward this effort. We have centered vaccine equity with local and national programs to address disparities in vaccine administration by bringing vaccine closer to the people who could benefit. HRSA’s Ryan White HIV/AIDS Program, CDC, SAMSHA, and HUD have worked with grantees to emphasize the urgent need for syndemic actions to respond to syndemic challenges. These agencies have provided clear messages about the importance of using the HIV, STIs, housing, and behavioral health funding, staff, and infrastructure to help control Monkeypox. It is critical that front line service providers in public health departments, medical clinics, substance abuse and mental health environments, housing providers, and community-based organizations continue to leverage these resources across these syndemics. We can work collaboratively across these interacting infections and social determinants to address the Monkeypox virus as a holistic health challenge, not in isolation. Providers that serve affected communities, particularly those living with HIV, must continue to leverage funding and programmatic flexibilities by:

• Using HIV care systems to support people with HIV and lead those at-risk for Monkeypox to the testing, prevention, and treatment services required to prevent poor outcomes of both diseases.
• Using established data-to-care strategies, and out-of-care lists, to reach the people most vulnerable for severe illness because they are not engaged in HIV care and use that outreach to offer them Monkeypox vaccine, behavioral guidance, and linkage to HIV care.
• Taking the opportunity presented by people seeking Monkeypox prevention to test for HIV and STIs and offer prevention or treatment services to avoid HIV infection or disease progression.
• Using housing resources to support people living with HIV and others so that they can prioritize their Monkeypox and HIV-related health seeking behaviors.
• Taking advantage of housing and mental health service encounters to engage people with HIV at-risk for Monkeypox and to link them with resources to identify, prevent, or mitigate Monkeypox and HIV disease progression.
• Provide HIV and Monkeypox resources and services for people seeking STI diagnosis and treatment.

Because Monkeypox exists as part of the syndemic of HIV, STIs, mental health and homelessness, the Administration is committed to treating it that way. Providers must continue to use all of the tools created by these important, and ground-breaking, funding and programmatic flexibilities. Service providers should use the expanded syndemic toolkit created by these flexibilities including HIV data-to-care, care navigation, housing resources, HIV prevention and care services, and Monkeypox vaccine and education to control this outbreak and support the wellness of people with and at-risk for HIV.

Resources

Learn More About Monkeypox: HHS Response to the Monkeypox Outbreak | HHS.gov
Ryan White Monkeypox Resources: Monkeypox Information | Ryan White HIV/AIDS Program (hrsa.gov)
Prevent Monkeypox: Prevention | Monkeypox | Poxvirus | CDC
Mental Health and Monkeypox: Monkeypox (MPV) | SAMHSA
HUD Monkeypox Resources: Homeless Systems Operational Management During Monkeypox and Talking to People Experiencing Homelessness About MPX (hudexchange.info)

References

1. Curran KG, Eberly K, Russell OO, et al. HIV and Sexually Transmitted Infections Among Persons with Monkeypox — Eight U.S. Jurisdictions, May 17–July 22, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1141–1147. DOI: http://dx.doi.org/10.15585/mmwr.mm7136a1
2. Miller MJ, Cash-Goldwasser S, Marx GE, et al. Severe Monkeypox in Hospitalized Patients — United States, August 10–October 10, 2022. MMWR Morb Mortal Wkly Rep. ePub: 26 October 2022. DOI: http://dx.doi.org/10.15585/mmwr.mm7144e1

Recognizing American Indian/Native American Heritage Month

November is American Indian/Native American Heritage Month. This November, Pacific AETC would like to acknowledge the over 150 indigenous tribes who are traditional stewards of the land that the Pacific region occupies in Arizona, California, Hawai’i, Nevada, and the US-Affiliated Pacific Islands. We are committed to the improvement and expansion of HIV testing, education, and treatment among indigenous populations and honor the longstanding history of those native to the land that we inhabit. 

The number of HIV diagnoses in American Indian/Alaska Native (AI/AN) people has increased over time. View the CDC’s latest data on HIV among AI/AN people and learn about the prevention challenges that some AI/AN people face.

Access fact sheets on HIV and American Indian/Alaska Native people

The following is cross-posted from AIDSVu:

In 2020, 190 American Indian/Alaska Natives were diagnosed with HIV.

Among Native communities, HIV impacts certain groups more than others – for example, Gay and Bisexual Men represented 82% of new HIV diagnoses among American Indian/Alaska Natives (AI/AN) men in 2020. In the same year, injection drug use accounted for 43% of new HIV diagnoses among AI/AN women. According to the Centers for Disease Control and Prevention, factors such as high rates of sexually transmitted diseases among AI/AN populations, alcohol and drug use, and cultural stigma result in disproportionate HIV rates among Native communities.

It is also important to recognize how social determinants of health can negatively impact HIV-related health outcomes for Native communities due to a lack of access to affordable health care and financial insecurity. For example:

• In 2019, 6.1% of the AI/AN population were unemployed, compared to 3.7% of the U.S. population.
• In the same year, 15% of the AI/AN population were uninsured, compared to 8% of the U.S. population.

More Resources

Clinician’s Guide: Working With Native Americans Living With HIV

HIV/AIDS Training Program from the Indian Health Service

Not One More: Fighting HIV/AIDS in Native American Communities

Cross-posted from HIV.gov

On the closing day of the 2022 US Conference on HIV/AIDS (USCHA) in Puerto Rico, the final plenary session focused on the response to the current monkeypox outbreak. On behalf of HIV.gov, Timothy P. Harrison, Ph.D., Principal Deputy Director for the Office of Infectious Disease and HIV/AIDS Policy, spoke with Dr. Demetre C. Daskalakis, White House National Monkeypox Response Deputy Coordinator, about the same topic.

The final session of the conference was a plenary focused on the national response to monkeypox, which is having a disproportionate impact on people with and experiencing risk for HIV. The session featured presenters from CDC, HRSA’s Ryan White HIV/AIDS Program, and representatives from a health department and community-based organizations in New York, Los Angeles, and Boston discussing their agencies’ approaches to addressing the monkeypox outbreak. Dr. Demetre Daskalakis underscored that a syndemic approach to the response to monkeypox is essential given both the common risk factors and populations affected by HIV, STIs, and monkeypox. He applauded and encouraged the important roles the HIV community has played and will continue to play in the monkeypox response. He highlighted opportunities to connect those getting the monkeypox vaccine or treatment with HIV testing and PrEP or HIV treatment, vital actions to end both the monkeypox outbreak and HIV epidemic equitably across all populations. (Follow HIV.gov’s Monkeypox page for more information and resources.)

Also featured in the closing session was a presentation of several panels of the National AIDS Memorial quilt and an invitation to participate in the new Change the Pattern initiative highlighting Black and Latino lives lost to HIV.

USCHA is the largest HIV-related gathering in the United States, bringing together thousands of participants from all segments of the HIV community. Organized by NMAC, the 2022 conference was held in San Juan, Puerto Rico, from October 8-11 with over 3,000 participants registered. The conference featured over 120 institutes, workshops, and posters addressing issues in biomedical HIV prevention, aging, service delivery, and telehealth, prioritizing the issues of people with HIV and the next steps in ending the epidemic.