Jeffrey Lennox, M.D., of Emory Univeristy, presents "The Southern HIV Epidemic - Clinical and Societal Implications" at AIDS Clinical Rounds

1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS

2. The$HIV$Epidemic$in$the$Southern$
United$States:$$
Societal$and$Clinical$Implica:ons$
1"
"
"
October"23,"2015"
Jeff$Lennox$MD$
Associate"Dean"for"Clinical"Research,"Emory"SOM"
Vice@Chair"of"Medicine"for"Grady"Affairs"
"

3. Area"we"will"discuss"
You"are"here"
World"PopulaJon"2015"

4. "
Straight"out"of"Midtown*@"
"
• 33"yo"admiMed"by"Dermatology"for"
disseminated"Zoster"unresponsive"
to"val@Acyclovir"
• Painless"skin"lesions"x"3"weeks.""
Mild"fever,"no"other"complaints"
• Lesions"began"aTer"geUng"
elephant"saliva"on"his"hands"at"
"the"Zoo"
• Tests:"HIV+,"CD4"344,"Blood"
Cultures@,"RPR"and"Trep"IgG"@"
*"Midtown(is(known(by(many(residents(as(
Atlanta's("Heart(of(the(Arts".((((Wikipedia"

5. Lecture"Outline"
1. Gratuitous"case"photos"to"alert"and"engage"the"
audience"
2. DescripJon"of"the"ongoing"HIV"epidemic"in"the"
South,"and"why"you"should"care"
3. Recent"research"(for(which(the(speaker(provided(
negligible(support(but(is(claiming(full(credit)"into"
factors"amplifying"the"epidemic"
4. Cool"informaJon"about"the"best"hospital"in"
America"to"care"for"paJents"with"HIV/AIDS"
5. Surprise"ending"during"which"a"UCSD"faculty"is"
slavishly"praised"

6. The"past"is"never"dead."Its"not"
even"past."
"
" " "William"Faulkner"
" " "New"Albany,"Mississippi"
"

7. 1989@"AIDS"Cases"Increasing"in"Southern"CiJes""

8. "
United"States"@"PopulaJon"Share"Growth"by"
State,"1980@2010"
"

9. "
United"States"–"PopulaJon"Density"by"County"
2010"""
"
"

10. The(New(Yorker,"2014"
“One"of"the"strangest"things"about"the"H.I.V."
epidemic"in"the"Deep"South…is"how"easily"most"
Americans"have"elided"it…It’s"a"plague"from"
some"anterior"Jme,"some"other"conJnent,"
something"our"kids"will"read"about"in"books"or"
that"we"glimpse"as"history…”"

11. Rates$of$Diagnoses$of$HIV$Infec:on$among$Adults$and$Adolescents,$
2013—United$States$and$6$Dependent$Areas$
N$=$47,958 $Total$Rate$=$18.0$
Note."Data"include"persons"with"a"diagnosis"of"HIV"infecJon"regardless"of"stage"of"disease"at"diagnosis."All"displayed"data"have"
been"staJsJcally"adjusted"to"account"for"reporJng"delays,"but"not"for"incomplete"reporJng."

12. 7,956" 6,061"
23,988"
8,765"
5,000"
10,000"
15,000"
20,000"
25,000"
#""
of"cases"
$
West" Midwest" South" Northeast"
"
United"States"@"""
New"Diagnosis"of"HIV"By"Region,"2013"
"
Region"
"

13. Persons"Living"with"HIV,"Percent"by"Region@2013"
West" Midwest" South" Northeast"

14. HIV"Diagnoses"by"PopulaJon"of"Area"of"Residence"
and"Region,"2013"
$$
MSA$of$
$≥500,000$
MSA$of$$
50,000W499,999$
NonW$
metropolitan$
Region$of$residence$$ No.$ Rate$ No.$ Rate$ No.$ Rate$
Northeast"
N"="8,765"
8,097" 21.5" 621" 7.8" 47" 2.7"
Midwest"
N"="6,061"
4,919" 15.6" 906" 5.8" 236" 2.6"
South"
N"="23,988"
18,424" 30.4" 4,197" 16.0" 1,367" 12.0"
West"
N"="7,965"
7,134" 15.7" 733" 5.8" 88" 2.8"
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have
been statistically adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000
population. Data exclude persons whose county of residence is unknown.
14

15. Rates$of$Stage$3$(AIDS)$Classifica:ons$among$Persons$with$HIV$
Infec:on,$2013—United$States$and$6$Dependent$Areas$
N$=$27,135$ $Total$Rate$=$8.5$
Note.((All"displayed"data"have"been"staJsJcally"adjusted"to"account"for"reporJng"delays,"but"not"for"incomplete"reporJng.""

16. PopulaJon@%"Black"by"County""

17. Rates$of$Diagnoses$of$HIV$Infec:on$among$Adult$and$Adolescent$
Blacks/African$Americans,$2013—United$States$
N$=$21,714 $Total$Rate$=$68.2$
Note.(Data"include"persons"with"a"diagnosis"of"HIV"infecJon"regardless"of"stage"of"disease"at"diagnosis."All"displayed"data"have"
been"staJsJcally"adjusted"to"account"for"reporJng"delays,"but"not"for"incomplete"reporJng.""

18. Rates of Persons Aged 25-34 Living with an HIV
Diagnosis, by County, 2012
Note. Data include persons with a diagnosis of HIV infection, regardless of the stage of disease at diagnosis, and have been statistically adjusted to account for reporting delays and missing risk-factor
information, but not for incomplete reporting.
Data Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention.
* Data are not shown to protect privacy. ** State health department requested not to release data.

19. Percent of Males Living with an HIV Diagnosis for whom
Infection is Attributed to Male-to-Male Sexual Contact,
by County, 2012
Note. Data include persons with a diagnosis of HIV infection, regardless of the stage of disease at diagnosis, and have been statistically adjusted to account for reporting delays and missing risk-factor
information, but not for incomplete reporting.
Data Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention.
* Data are not shown to protect privacy. ** State health department requested not to release data.

20. Percent of Males Living with an HIV Diagnosis for whom
Infection is Attributed to Heterosexual Contact, by State, 2012
Note."Data"include"persons"with"a"diagnosis"of"HIV"infecJon,"regardless"of"the"stage"of"disease"at"diagnosis,"and"have"been"staJsJcally"adjusted"to"account"for"reporJng"delays"and"missing"risk@
factor"informaJon,"but"not"for"incomplete"reporJng."""
Data"Source:"Centers"for"Disease"Control"and"PrevenJon,"NaJonal"Center"for"HIV/AIDS,"Viral"HepaJJs,"STD,"and"TB"PrevenJon,"Division"of"HIV/AIDS"PrevenJon.
* Data are not shown to protect privacy. ** State health department requested not to release data.

21. Percent of Females Living with an HIV Diagnosis for whom
Infection is Attributed to Heterosexual Contact, by County, 2012
Note."Data"include"persons"with"a"diagnosis"of"HIV"infecJon,"regardless"of"the"stage"of"disease"at"diagnosis,"and"have"been"staJsJcally"adjusted"to"account"for"reporJng"delays"and"missing"risk@
factor"informaJon,"but"not"for"incomplete"reporJng."""
Data"Source:"Centers"for"Disease"Control"and"PrevenJon,"NaJonal"Center"for"HIV/AIDS,"Viral"HepaJJs,"STD,"and"TB"PrevenJon,"Division"of"HIV/AIDS"PrevenJon.
* Data are not shown to protect privacy. ** State health department requested not to release data.

22. Rates$of$Diagnoses$of$HIV$Infec:on$among$Adult$and$
Adolescent$Hispanics/La:nosa,$2013—United$States$$
N$=$10,104 $Total$Rate$=$24.7$
Note.(Data"include"persons"with"a"diagnosis"of"HIV"infecJon"regardless"of"stage"of"disease"at"diagnosis."All"displayed"data"have"been"
staJsJcally"adjusted"to"account"for"reporJng"delays,"but"not"for"incomplete"reporJng.""
a"Hispanics/LaJnos"can"be"of"any"race."

23. Rates$of$Diagnoses$of$HIV$Infec:on$among$Adult$and$
Adolescent$Whites,$2013—United$States$
N$=$13,075 $Total$Rate$=$7.7$
Note.(Data"include"persons"with"a"diagnosis"of"HIV"infecJon"regardless"of"stage"of"disease"at"diagnosis."All"displayed"data"have"been"
staJsJcally"adjusted"to"account"for"reporJng"delays,"but"not"for"incomplete"reporJng."

24. Rates$of$Stage$3$(AIDS)$Classifica:ons$among$Persons$with$HIV$
Infec:on,$2013—United$States$and$6$Dependent$Areas$
N$=$27,135$ $Total$Rate$=$8.5$
Note.((All"displayed"data"have"been"staJsJcally"adjusted"to"account"for"reporJng"delays,"but"not"for"incomplete"reporJng.""

25. Diagnoses"of"HIV"InfecJon"among"MSM"by"Region"of"
Residence"and"Race/Ethnicity@2013$

26. Rates of Females Living with an HIV Diagnosis,
by County, 2012
Note. Data include persons with a diagnosis of HIV infection, regardless of the stage of disease at diagnosis, and have been statistically adjusted to account for reporting delays and missing risk-factor
information, but not for incomplete reporting.
Data Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention.
* Data are not shown to protect privacy. ** State health department requested not to release data.

27. "
Eastern"United"States"@"""
HIV"Prevalence"vs"Poverty"Prevalence"
"

28. "
Eastern"United"States"@"""
HIV"Prevalence"and""High"School"GraduaJon"Rate"
"

29. Median Household Income
Rates of Persons Living with an HIV Diagnosis &
Median Household Income, by County, 2012
Note. Data include persons with a diagnosis of HIV infection, regardless of the stage of disease at diagnosis, and have been statistically adjusted to account for reporting delays and missing risk-factor
information, but not for incomplete reporting.
Data Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention.
* Data are not shown to protect privacy. ** State health department requested not to release data.
Persons Living with an HIV Diagnosis

30. Gonorrhea$—$Rates$of$Reported$Cases$by$County,$
United$States,$2013$

31. Primary$and$Secondary$Syphilis—Rates$of$Reported$Cases$by$
State,$United$States$and$Outlying$Areas,$2013$
NOTE:$The"total"rate"of"primary"and"secondary"syphilis"for"the"United"States"and"outlying"areas"(Guam,"Puerto"
Rico,"and"Virgin"Islands)"was"5.6"per"100,000"populaJon."

32. Primary$and$Secondary$Syphilis—Reported$Cases*$by$Stage,$
Sex,$and$Sexual$Behavior,$$
United$States,$2013$
*Of"the"reported"male"cases"of"primary"and"secondary"syphilis,"16.9%"were"missing"sex"of"sex"partner"informaJon."
†MSW=men"who"have"sex"with"women"only;"MSM=men"who"have"sex"with"men.""

34. Most"Common"Drugs"cited"as"Reason"for"Treatment"
Admission"

35. Percent of Males Living with an HIV Diagnosis for whom
Infection is Attributed to Injection Drug Use, by County, 2012
Note."Data"include"persons"with"a"diagnosis"of"HIV"infecJon,"regardless"of"the"stage"of"disease"at"diagnosis,"and"have"been"staJsJcally"adjusted"to"account"for"reporJng"delays"and"missing"risk@
factor"informaJon,"but"not"for"incomplete"reporJng."""
Data"Source:"Centers"for"Disease"Control"and"PrevenJon,"NaJonal"Center"for"HIV/AIDS,"Viral"HepaJJs,"STD,"and"TB"PrevenJon,"Division"of"HIV/AIDS"PrevenJon.
* Data are not shown to protect privacy. ** State health department requested not to release data.

36. SJmulant"Use"Preference@"2007"
Red=Meth""""Blue=Cocaine"

37. "
Atlanta@"an"alternate"view"
"

38. HIV Distribution in Atlanta- by Zip code

39. • HIV"prevalence"among"MSM"is"as"high"as"60%"in"
certain"populaJons""
• In"the"HPTN"061"(Brothers)"study"the"incidence"
rate"among"Black"MSM"(BMSM)"was"6%"per"year"
• Reasons"for"these"racial"dispariJes"remain"unclear"
Background:"HIV"and"MSM"in"Atlanta"

40. Population Transmission Risk
Kelley et al – PLoS One 2012
• ‘Community viral load’ does not capture disparities in HIV exposure
between groups because it does not incorporate HIV prevalence.
▫ No difference in CVL or PVL between black and white MSM
• Synthesized data on disparities in HIV prevalence, viral load with
racial-patterns in sexual partnering
▫ 25% of BMSM vs. 8% of WMSM had HIV VL>400 copies/ml
▫ Racially concordant partnerships: BMSM 71%; WMSM 70%
• Despite similar levels of sexual risk behavior (partner # and
unprotected anal sex), BMSM have higher chance of encountering an
HIV-infected and unsuppressed partner
▫ WMSM reach 50% chance with 7 partners
▫ BMSM reach 50% chance with just 3 partners

41. Involve[men]t
Race and Age Disparities in HIV/STI Incidence and
Prevalence Among MSM in Atlanta: 2009-2014
• Principal investigator
▫ Patrick Sullivan
• Co-Investigators
▫ Hannah Cooper
▫ Carlos del Rio
▫ Ralph DiClemente
▫ Paula Frew
▫ Colleen F. Kelley
▫ john Peterson (GSU)
▫ Eli Rosenberg
▫ Laura F. Salazar (GSU)
▫ Travis Sanchez
▫ Gina Wingood

42. Study Design
• Recruitment
▫ MSM community venues and Facebook
• Eligibility
▫ Black and white, non-Hispanic
▫ Currently living in Atlanta MSA
▫ Ages 18 – 39 (earlier recruits had no upper limit)
▫ Sexually active with men, not in a main partnership
▫ NOT HIV-status-dependent
• Procedures
▫ Testing: HIV, Chlamydia, Gonorrhea, Syphilis
▫ Extensive self-admin computer questionnaire
• Enrollment Numbers
▫ 803 men took part in baseline
! 30% were prevalent HIV-positive at baseline
▫ 562 HIV-negative MSM enrolled in prospective
! 79% retained in study at 24 months
Baseline
Month 3
Month 6
Month 12
Month 18
Month 24
HIV/STI testing,
Questionnaire
HIV/STI testing,
Questionnaire
HIV/STI testing,
Questionnaire
HIV/STI testing,
Questionnaire
HIV/STI testing,
Questionnaire
HIV/STI testing,
Questionnaire

43. HIV Prevalence, by Race and Age
Sullivan et al – PLoS One 2014

44. Participants at Enrollment
Sullivan et al – PLoS One 2014

45. Comparisons of Factors by Race
Sullivan et al – PLoS One 2014
• Compared to white MSM, black MSM reported:
▫ Fewer sexual partners and sex risks
▫ Less drug use
▫ A higher degree of same-race partnering
▫ Similar ages of partners
▫ Less pre-sexual discussion of HIV status
▫ Lower socioeconomic status
(poverty, employment, insurance)
▫ Living in more disadvantaged census tracts
Social
determinants
Partner pool /
network
Individual risk
behaviors

46. HIV Incidence
Sullivan et al-- Ann Epi. 2015
Black MSM White MSM
Overall
Incidence rate 6.6% / year 1.7% / year
New HIV infections 24 8
% HIV-positive at end of study 11.3% 3.6%
Age 18 – 24
Incidence rate 12.1% / year 1.0 % / year
New HIV infections 16 1
% HIV-positive at end of study 16.6% 1.6%
Age 25+
Incidence rate 3.5% / year 1.9% / year
New HIV infections 8 7
% HIV-positive at end of study 6.0% 4.5%

47. What explains HIV incidence?
Sullivan et al--Ann Epi. 2015
Factor
Rate
(% / year)
Rate Ratio
Helps explain
disparity?
Black participant 6.6 3.8
--
White participant 1.7 ref.
Health Insurance 2.6 ref.
YES
No health Insurance 6.3 2.4
UAI 5.3 4.8
NO
No UAI 1.1 ref.
Older partners (≥10 y) 8.6 2.8
NO
No older partners 3.1 ref.
Black partners 8.6 4.5
YESNo black partners 1.9 ref.
Social
determinants
Individual risk
behaviors
Partner pool /
network

48. Clinical"and"Research"ImplicaJons"of"the"Atlanta"
Epidemic"""
• Being"an"HIV"treatment"provider"in"Atlanta"is"
like…"
hMp://www.medicalschoolsuccess.com"

49. HIV/AIDS"Admissions"Grady"Memorial"
Hospital"2001"@"2014"
0
500
1000
1500
2000
2500
3000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Patients
Admissions

50. New"HIV"diagnosis"during"a"hospitalizaJon"at"
GMH"(2001"–"2014)"
0
50
100
150
200
250
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
New Dx

51. Special"Immunology"Service@"hospital"
diagnosis"
ICD-9 code Diagnosis total #
42 HIV 5265
486
Pneumonia organism
unspecified 1516
584.9 Acute Kidney Failure 1365
285.9 Anemia unspecified 1332
Asymptomatic HIV
status
Various Malignancies
1267
?

52. Why"are"People"who"know"their"status"sJll"
geUng"admiMed"with"AIDS?"""Cascades"of"Care.."
79%"
59%"
40%"
24%"
19%"
80%"
62%"
41%"
36%"
28%"
0%"
20%"
40%"
60%"
80%"
100%"
HIV"Infected" Diagnosed" Linked"to"Care" Retained"in"
Care"
Prescribed"ART" Virally"
Supressed"
Gardner"et"al.""
CDC"
1,106,400$
1,178,350$
Gardner,…"del"Rio,.."et"al."CID."2011@"Emory$
Cohen""et"al."MMWR."2011$

55. Grady"Ponce"de"Leon"Center"
A"Publicly"Funded,"TerJary"HIV"Care"clinic"
Infusion
Center
Pharmacy,
X-ray
Main Clinic
Pediatrics
Women
Research
Psych
Housing
Oral Health
CBOs
Case Management

56. 1"
8"
39"
48"
3"
0"
10"
20"
30"
40"
50"
%$
≤"12" 13@24" 25@44" 45@64" ≥"65"
Grady"Ponce"de"Leon"Center@"Age"Range"
5439"HIV@Infected"PaJents"in"2014"
Age"(yrs)"

57. Grady"Ponce"de"Leon"Center@"PaJent"
Demographics"
AIDS$
77%$
NonW
AIDS$
23%$
CDCWStage$
Black$
83%$
White$
10%$
Hispanic$
5%$
Race$

58. Grady"Ponce"de"Leon"Center@"Gender"and"Income"
Male$$
73%$
Female
27%$
Gender$
<$$20K$
78%$
>$40K$
7%$
$20W39K$
15%$
Income$

59. The"care"conJnuum"for"paJents"newly"diagnosed"
with"HIV"as"an"inpaJent"at"GMH"2011@2012"
N$=$94$
Linkage$
Reten:on$ VS$

60. Research"ImplicaJons"of"the"Ongoing"Epidemic"
• In"1993"when"the"Ponce"Center"was"opened"there"was"
less"than"$5M"in"NIH@funded"HIV"research"at"Emory.""
• In"2004"a"facility"dedicated"to"HIV"Vaccine"and"
PrevenJon"studies,"the"Hope"Clinic,"was"opened"""
• Study"PI’s"from"the"Schools"of"Medicine,"Nursing,"Public"
Health,"and"the"Vaccine"Center"enroll"subjects"at"both"
centers"
• In"2015"there"are"mulJple"RO1’s,"U’s,"and"5"acJve"K"
awards"located"at"the"Ponce"and"Hope"sites"
• Total"Emory"NIH@funded"research"exceeds"$50M"
"

61. UCSF: San Francisco, CA
USC: Los Angeles, CA
RUSH: Chicago, IL
Einstein: Bronx,
NY SUNY: Brooklyn,
NY
JHU: Baltimore, MD
(Data Center)Georgetown: Washington, D.C.
Women’s"Interagency"HIV"Study"Sites@"
2013"

64. PrevenJon"Research"is"Growing"
• HVTN@"Atlanta"usually"the"#1"or"#2"enrolling"site"
• HPTN@"will"open"3"studies"in"the"next"12"months"
enrolling"nearly"300"high"risk"MSMs"to"test"new"forms"
of"PREP."""
• Non@network"studies"will"enroll"nearly"another"300.""
• Most"NIH@funded"studies,"for"obvious"reasons,"are"
not"enrolling"at"risk,"rural"inhabitants."
• Tuskegee,"Alabama"is"a"real"place"less"than"2"hours"
from"Atlanta."Every"precauJon"must"be"made"to"
never"put"the"community"at"risk."The"community"
must"own"the"table,"not"just"be"given"a"seat."

65. HIV"and"the"South"
• Transmission"rampant"in"among"MSM,"black">"white;"
and"to"a"lesser"extent"urban"and"rural"straight"men"and"
women@"who"will"be"the"source"of"a"sustained"endemic"
infecJon"
• Despite"significant"gains"over"the"last"quarter"century,"
the"region"sJll"trails"the"rest"of"the"country"in"
educaJonal"aMainment,"health"care"access,"and"income"""
• This"beauJful"land"of"kind"people"leads"the"country"in"
most"health"problems,"parJcularly"HIV"and"other"STIs."
Whether"this"can"be"changed"in"our"lifeJmes"is"an"open"
quesJon"

66. HIV and Seronegative Secondary Syphilis
• Very"few"cases"described"
• 2"cases"reported"over"a"span"of"12"years"by"one"
physician,"Chuck"Hicks"
• Our"Case@"Lues"maligna " " " ""
– PCR"of"biopsy"done"at"CDC"posiJve"for"T."pallidum"
– Skin"Biopsy@"pathology"c/w"syphilis"
– Rx@"2.4"MU"Benzathine"PCNG"
– Rash"resolved"over"2"weeks"

67. • Thank you to these friends for their help and for being
great human beings
Carlos del Rio, Colleen Kelley, Igho Ofotokun, Wendy Armstrong, Jonathan Colasanti

68. QuesJons?"