Introduction
In the US, the epidemiology of HIV/AIDS varies widely across states and counties. This global pandemic was initially prevalent among young gay men in the West in the 1980s (CDC, 2017). Presently, human immunodeficiency virus (HIV) infection and the related condition of AIDS – acquired immunodeficiency syndrome – affects people of different ages, ethnicities, and sexual orientations. Epidemiologic diversity means that some regions have a higher disease incidence than others. Nationally, HIV diagnoses are most prevalent in the South, which is inhabited by 38% of the American population (CDC, 2017). The new cases reported in the Southern states, including Florida, occur in urban, suburban, and rural areas.
The demographic diversity and expansiveness of Florida present specific challenges to HIV prevention and management. Understanding the areas and characteristics of affected demographic groups will help support preventive measures and treatment. This paper describes the epidemiology of HIV/AIDS in Florida based on current incidence and prevalence data, surveillance methods, at-risk and affected populations, and screening and diagnosis.
Background and Significance of the Disease
Definition
HIV in full means the human immunodeficiency virus. The viral agent targets and destroys the body’s immune system, precisely the CD4 cells, gradually a person’s ability to fight off infections (CDC, 2017). A weakened immune system makes one vulnerable to opportunistic diseases, a condition called acquired immune deficiency syndrome or AIDS.
Description
HIV transmission involves exposure to particular body fluids, such as blood, breast milk, and seminal and vaginal fluids (CDC, 2017). The infection risk is highest in exposures related to rectal, vaginal, or penile mucosa (sexual route) and direct contact with contaminated blood through injections. The condition has no effective treatment; however, it can be managed with adequate medical care.
Signs and Symptoms
Initial symptoms of HIV infection occur within the first two months after contact with the virus (CDC, 2017). Most individuals experience flu-like symptoms, such as fever, migraines, tiredness, and hypertrophied lymph nodes before an asymptomatic period sets in (CDC, 2017). Advanced infection results in AIDS, which increases susceptibility to opportunistic infections. AIDS symptoms are fast weight loss, rashes/lesions, vomiting, diarrhea, coughs, etc.
Current Incidence/Prevalence Statistics
According to the CDC (2017), the prevalence of HIV among adults (>13 years) in the US stands at 1.1 million cases based on the latest statistics (2014 data), an 18 percent drop from the 2008 estimate. Florida is among the states with the highest number of HIV cases, at 98,650. HIV prevalence is greatest in Miami-Dade County (MDC), at 1,411 persons. New annual HIV diagnoses are estimated to be 37,600 in the US with MDC having the highest rate of all urban areas nationally in 2009 – 56.6 per 100,000 (Pellowski, Kalichman, Matthews, & Adler, 2013). Almost 75 percent of new diagnoses in this region are among gay men. By race, HIV incidence is greatest in African Americans (112.4 per 100,000) followed by 38.8 for Caucasians and 34.5 for Latinos (Carey et al., 2015). However, this rate has declined in gays and injection drug users by 36 and 56 percent, respectively, since 2008 (CDC, 2017).
A summary of HIV prevalence rates in MDC, Florida, and the US is given in Table 1 below. The significance of understanding the geographical diversity in HIV prevalence is to inform effective preventive measures targeting at-risk populations in specific areas.
Table 1: HIV Prevalence by County, State, and National Statistics.
Current Surveillance Methods
The federal agency (CDC) implements various HIV surveillance methods to gather data and monitor national HIV/AIDS incidence based on new diagnoses. Through the Division of HIV/AIDS Prevention, the CDC monitors HIV cases across 50 states and other jurisdictions with a standardized report form that collects data on “demographic characteristics, transmission mode, viral load, and immune status” (CDC, 2017, para. 5). The two surveillance methods currently in use include the Medical Monitoring Project (MMP) and the National HIV Behavioral Surveillance (NHBS).
MMP collects national data on “clinical and behavioral outcomes” of HIV-diagnosed individuals under treatment in the US and Puerto Rico (CDC, 2017, para. 8). It employs a two-stage sampling approach to obtain representative outcome information from an annual sample of 10,900 people. The data gathered include demographics, availability of care, medication compliance, substance use, sexual relations, etc. Further information collected includes clinical outcomes and treatments taken. The aim is to identify disparities in care and inform policy actions. NHBS gathers surveillance data in the at-risk demographic groups: gay men, injection-drug users, and heterosexuals (CDC, 2017). In each cycle (n=500), data on risky practices and utilization of HIV prevention services is obtained anonymously to determine behavioral risks and resource usage levels.
In Florida, HIV/AIDS surveillance involves tracking the time the initial diagnosis was made and the year of reporting, i.e., the instance the case was documented in the State Department of Health system (CDC, 2017). HIV diagnosis and reporting may not occur in the same year. Based on CDC criteria, a reportable case must involve detectable viral load, irrespective of patient diagnostic history. Thus, undetectable levels of the virus in the blood are not entered in the Reporting System. In addition to prevalence surveillance, Florida also tracks persons living with HIV (PLWH) to manage this disease through the healthcare continuum. In 2016, 114,772 cases were reported, of which 92 percent were in care and 60 percent had an undetectable viral load (CDC, 2017).
HIV/AIDS is mandated for reporting by all providers in Miami-Dade County except the Department of Corrections. Surveillance involves an electronic HIV/AIDS reporting system of Florida’s Department of Health that captures cumulative AIDS cases by age, sex, ethnic group/race, exposure category, and perinatal infection as reported by facilities in the county (CDC, 2017). The report indicates that HIV prevalence is highest among blacks (49.8%) followed by Hispanics (36.7%) and Whites (12.9%) (Pellowski et al., 2013).
Descriptive Epidemiological Analysis
A key feature of the epidemiological profile of HIV/AIDS in the US is the regional variations in incidence rates. Nearly half of the HIV diagnoses (18.5 per 100,000 persons) were reported in the South in 2015 (CDC, 2017). In Florida, the rate is among the highest, at 27.9 diagnoses per 100,000 people. HIV diagnoses by race show that the prevalence rate is highest among African Americans (12% of the national population), at 46 percent in 2013 (Pellowski et al., 2013). Infection cases reported among Hispanics and Whites stood at 21 and 28 percent, respectively.
In Florida, of the 6,132 cases, black adults accounted for 41 percent of new diagnoses compared to 31 percent of Caucasians and 26 percent of Latinos in 2014 (Carey et al., 2015). In MDC, African Americans account for 49.8 percent of reported AIDS cases followed by Hispanics, at 35.7 percent. By race, the subgroups with the highest HIV burden include blacks and Hispanics. By transmission mode, gay men account for 63 percent, followed by black heterosexuals (females) – at 25 percent (Carey et al., 2015). The least affected subgroups are injection drug users, including those who may be homosexuals (3 percent). Therefore, prevention programs should primarily target three at-risk groups: gay men populations, black heterosexual females, and Hispanics in MDC’s urban, suburban, and rural areas.
HIV/AIDS prevention or care is a matter of economics. Schackman et al. (2015), using computer models, estimates the average lifetime medical cost at $597,300 per HIV-infected person under care 5.1 years after diagnosis in the US. Antiretroviral therapy accounts for 60 percent of these costs, while 15 percent is spent on treating opportunistic diseases (Schackman et al., 2015). The estimated lifetime cost savings from non-infection is about $229,800 per person. The CDC spends $343.7 million yearly in community-level preventive measures in the worst-hit areas (CDC, 2017). The social costs of HIV infection are associated with SES disparities. Personal characteristics that are related to high HIV incidence include poverty, low educational levels, and minority stress. For example, 44 percent of all new HIV diagnoses involve blacks despite constituting only about 14 percent of the national population (CDC, 2017). Social stigma against gay men explains the disproportionate impact of HIV in this group – 41.2 percent in MDC.
Screening and Diagnosis
CDC-recommended HIV testing involves diagnostic algorithms that optimize multiple HIV-1 immunoassay results. Specimens turning positive in the initial screening are subjected to a confirmatory HIV-1 antibody test that uses either the Western blotting or IFA technique (Branson et al., 2014). In the US, the recommended screening method is the fourth-generation HIV immunoassay technology or combo assay that is highly sensitive to human IgM, IgG, and p24 antibodies produced against HIV-1 antigens.
Updated CDC-APHL national guidelines or standards for HIV diagnosis require the use of sera or plasma samples. The initial laboratory test should use FDA-approved fourth-generation immunoassay to screen for “established infection with HIV-1 or HIV-2 and for acute HIV-1” (Branson et al., 2014, p. 8). No additional testing is necessary if the results are negative. However, in the case of reactive specimens, a repeat test (antibody-differentiation assay) is recommended to distinguish HIV-1 from HIV-2. The immunoassay differentiates HIV-2 from HIV-1 faster than the Western blotting technique (Branson et al., 2014). Non-reactive specimens in the antibody-differentiation assay should be screened with HIV-1 NAT to detect severe infection.
The sensitivity, specificity, positive predictive value, and cost vary between screening tests. Specifically, two FDA-approved fourth-generation HIV-1/HIV-2 immunoassays have been shown to have HIV-2 and HIV-1 sensitivities of 99.76-100 percent and 62-83 percent, respectively (Conway et al., 2014). Their specificities range between 99.5 and 100 percent. The positive predictive value of the algorithm implemented in the HIV combo assays is 100 percent for HIV-1, compared to 98 percent for third-generation technology (Branson et al., 2014). Thus, the recommended screening method has high accuracy. Although the algorithm is more accurate, related testing costs are high. The estimated cost per HIV-1 infection is $5,027-14,400 for samples with one percent HIV-1 and 0.1 percent acute HIV-1 seroprevalence (Conway et al., 2014). Current guidelines recommend combo assays for the diagnosis of patients with acute HIV-1 infection (Conway et al., 2014). These persons have a high viral load, and therefore, account for most sexual transmissions.
Plan of Action
Epidemiologic data reveal that the MDC region reports the highest rate of new HIV diagnoses nationally, which calls for improved preventive services. My plan of action will prioritize condom availability (prevention), minority engagement, and enhanced access to treatment. The preventive services will target the at-risk populations in zip codes with the highest HIV incidence rates. Centralized condom distribution in hospitals in MDC means that high-priority populations – sex workers, gay men, and low-income persons – cannot access them. Improved condom availability to high-risk HIV-negative groups has been shown to prevent new infections (Carey et al., 2015). My plan is to distribute male and female condoms to local distributors through collaboration with the Department of Health. The outcomes of this preventive service will include the number of condoms handed out to high-risk populations per month and reported new HIV diagnoses in specific zip codes.
A second intervention involves engaging the MDC minority, including gay and transgender persons, African Americans, and Hispanics, through volunteer outreach programs. The aim is to improve patient outcomes through linking new HIV diagnoses to treatment, which has been a challenge in MDC due to social stigma, culturally insensitive services, and immigration issues (Carey et al., 2015). A measurable outcome of this initiative includes the newly diagnosed cases retained in care. The third priority area of my plan includes improved access to antiretroviral therapy by low-income individuals through a provider-accessible confidential database. Most persons living with HIV (PLWHs) in MDC lack the ability to pay for medical care (Carey et al., 2015). The intervention will help facilities organize for medical support, outpatient care, and counseling to low-income PLWHs. The measurable outcome of this initiative will include the number of eligible PLWHs receiving medical care based on provider records.
Conclusion
HIV/AIDS is a viral disease principally transmitted through sexual intercourse. It is associated with weakened immunity and susceptibility to opportunistic illnesses. The rate of new HIV/AIDS diagnoses in the MDC has reached epidemic proportions – 56.6 per 100,000. Effective responses may include improved surveillance, tailored preventive services, and access to treatment by high-priority populations in this region. Lab tests should also follow national guidelines for accurate diagnosis and care. The proposed plan of the action centers on prevention (condom availability), minority engagement, and improved access to treatment by MDC’s low-income PLWHs.
References
Branson, B. M., Owen, S. M., Wesolowski, L. G., Bennett, B., Werner, B. G., Wroblewski, K. E., & Pentella, M. A. (2014). Laboratory testing for the diagnosis of HIV infection: Updated recommendations. Atlanta, GA: Centers for Disease Control and Prevention.
Carey, J. W., Lalota, M., Villamizar, K., McElroy, T., Wilson, M. M., Garcia, J., … Flores, S. A. (2015). Using high-impact HIV prevention to achieve the national HIV/AIDS strategic goals in Miami-Dade County, Florida: A case study. Journal of Public Health Management & Practice, 21(6), 584-593. Web.
Centers for Disease Control and Prevention [CDC]. (2017). HIV in the United States by geographic distribution. Web.
Conway, D. P., Holt, M., McNulty, A., Couldwell, D. L., Smith, D. E., Davis, S. C., Guy, R. (2014). Multi-centre evaluation of the determine HIV combo assay when used for point of care testing in a high risk clinic-based population. PloS One, 9(4), 1-14. Web.
Pellowski, J. A., Kalichman, S. C., Matthews, K. A., & Adler, N. (2013). A pandemic of the poor: Social disadvantage and the U.S. HIV epidemic. American Psychologist, 68(4), 197-209. Web.
Schackman, B. R., Fleishman, J. A., Su, A. E., Berkowitz, B. K., Moore, R. D., Walensky, R. P., … Losina, E. (2015). The lifetime medical cost savings from preventing HIV in the United States. Medical Care, 53(4), 293-301. Web.