The problem of a new HIV Epidemic.

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Information about The problem of a new HIV Epidemic.
Health & Medicine

Published on June 28, 2014

Author: daniellapedroso

Source: slideshare.net

Description

This presentation offers stats, trends, and factors associated with higher HIV-infection risk and how clinicians can attend to it.This was my presentation for Bayless Bahavioral Health- Didactic training on 12.10.13, it explores the HIV problem in the US and AZ and

Argosy University/ Phoenix Campus Daniella M. Pedroso, M.S., M.A.

Introduction: How I got here • Practicum student at Bayless 2011/2012 • Dissertation: Surviving the epidemic-50+ HIV –MSM- qualitative • Why this interests me • First presentation of this topic LGBT course- updated my 2006 stats for this presentation • Focus on US and explore AZ stats • Need to be informed- integrated healthcare

Basics of HIV/ AIDS • HIV • AIDS • Transmission • Tests Western Blot (antibody) Rapid test (blood,saliva) 3 month window period. -Plasma HIV RNA test- detects recent infection • Treatments: Antiretroviral therapy (ART/ HAART) • Curiosity: HIV superinfection • Co-infection with TB and Hep B , C

Clinical Progression of HIV

Brief History and Overview • Since the height of the epidemic in the mid-1980s, the annual number of new HIV infections in the United States has been reduced by more than two-thirds (130,000 to 50,000 annually) • But… As a result of treatment advances since the late 1990s, the number of people living with HIV (HIV prevalence) has increased dramatically. • With continued increases in the number of people living with HIV thanks to effective HIV medications, there are more opportunities for HIV transmission than ever before.

History • 1981: Rare lung infection, opportunistic infections and Kaposi’s sarcoma flood CDC • 1982: “AIDS” used for first time to describe symptoms • 1985: Blood banks start screening • 1988: WHO declares December 1st: World AIDS Day • 1992: AIDS becomes number one cause of death for U.S. men ages 25 to 44. • 1993: Movie Philadelphia • 1994: AIDS becomes leading cause of death for all Americans ages 25 to 44 • 1995: 500,000 cases of AIDS have been reported in the U.S. CDC began recommending routine HIV screening of pregnant women • 1996: AIDS no longer leading cause of death for all Americans ages 25-44, although remains leading cause of death for African Americans in same age group

History • 1997: Highly Active Antiretroviral Therapy (HAART) becomes the new standard in AIDS treatment. AIDS-related deaths in the U.S. decline by 47% compared to previous year • 1998: Clinton announces special package of initiatives aimed at reducing impact of HIV/AIDS on racial and ethnic minorities • Congress funds “Minority AIDS Initiative”: $156 million to improve effectiveness in preventing and treating HIV/AIDS in African American, Hispanic, and other minority communities • 2002: HIV/AIDS leading cause of death in sub-Saharan Africa and fourth biggest global killer • Worldwide, 10 million young people, aged 15-24, and almost 3 million children under 15 living with HIV. Approximately 3.5 million new infections will occur in sub-Saharan Africa and kill estimated 2.4 million Africans.

History • 2003 – present: • Since the height of the epidemic in the mid-1980s, the annual number of new HIV infections in the United States has been reduced by more than two-thirds (130,000 to 50,000 annually) • But… As a result of treatment advances since the late 1990s, the number of people living with HIV (HIV prevalence) has increased dramatically. • With continued increases in the number of people living with HIV thanks to effective HIV medications, there are more opportunities for HIV transmission than ever before. • Still no vaccine, and no “cure”

Before I start with numbers… What’s your bias? • Potential clinician biases or Sterotypes • Risk populations: MSM, sex workers, drug users only?– hetero women not in risk? - Beliefs about elderly—(un) comfortable discussing their sex lives or assume they don’t inject drugs - Others?

CDC- HIV Prevalence and New Infections, 1980-2010

Current Trends • CDC estimates 1.1 million people in the US are living with HIV • Nearly one in five of those are not aware that they are infected. • Approximately 50,000 people become newly infect • Continued growth in the number of people living with HIV ultimately may lead to more new infections

Heavily Affected Subgroups- CDC

New HIV Infections byTransmission Category, 1980 – 2010 CDC Trends-

HIV EpidemiologyProgram,AZDHS 2013Annual Report Adult IDU 9% Adult MSM 58% Adult MSM and IDU 4% HRH 15% NRR 2% Presumed Heterosexual 11% Vertical 1% Arizona HIV/AIDS Incidence by Mode of Transmission, 2012 MSM =Men Who Have Sex with Men IDU = Injection Drug User HET= High-Risk Heterosexual NRR =No Risk Reported The United States estimate does not include an NRR category

RACE/ ETHNICITY AND SEX

Adult IDU 7% Adult MSM 68% Adult MSM and IDU 5% HRH 8% NRR 2% Presumed Heterosexual 9% Vertical 1% Arizona HIV/AIDS Incidence Among Males by Mode of Transmission, 2012 Source: AZDHS.gov

Adult IDU 16% HRH 56% NRR 2% Presumed Heterosexual 23% Vertical 3% Arizona HIV/AIDS Incidence Among Females by Mode of Transmission, 2012 Source: AZDHS.gov 2013 MSM =Men Who Have Sex with Men IDU = Injection Drug User HET= High-Risk Heterosexual NRR =No Risk Reported The United States estimate does not include an NRR category

Populations at Higher Risk for HIV: Racial and Ethnic Health Inequities

Estimated New Infections among Black Women

African-American and Latinos African Americans are the racial/ethnic group most affected by HIV. • Young African American gay, bisexual, and other men who have sex with men are especially at risk of HIV infection. • New HIV infections among African American women decreased for the first time in 2010. Latinos are disproportionately affected by HIV. • In 2009, Latinos accounted for 20% of new HIV infections in the United States while representing approximately 16% of the total US population. • Latino MSM are particularly affected by HIV.

Heterosexual Women HIV Among Women (March 2013- CDC) • As of the end of 2010, one in four people living with a diagnosis of HIV infection in the United States were women. • Black/African American women and Latinas are disproportionately affected by HIV infection compared with women of other races/ethnicities. • New HIV infections among black/African American women decreased in 2010 • All pregnant women should be screened for HIV as early as possible during each pregnancy. • Women with HIV who take antiretroviral medication during pregnancy as recommended can reduce the risk of transmitting HIV to their babies to less than 1%. • HIV disproportionately affects black/African American children in the United States.

MSM

2010- New HIV infections

Review of literature: Explaining Unsafe Sex

AIDS optimism, condom fatigue, or self-esteem? Explaining unsafe sex among gay and bisexual men • “Barebacking” is related to: • AIDS Optimism theory: “People became more complacent following the introduction of more effective treatments (primarily protease inhibitors) have lost a sense of urgency surrounding AIDS and have been reverting to unsafe sex” (p 238). • This is the most widely prevailing explanation for the rising rates of HIV infections. (Adam, et al 2005)

Reasons men who had abandoned condom use altogether: • condoms and erectile difficulties (1/3 of the 102 high-risk men complained condoms decreases stimulation, leading to loss of erection. • many of the remaining participants said it causes minor loss of sensation (this included men who take a more receptive role) • the receptive individuals complained water-based lubricants tend to dry, leading to abrasion; • others included complaints of condom size or slippage, as well as condom tearing for those with penile piercing. • Men became complacent not to lose their partner (who dislikes condom use.) • Other adaptations included: shifting from taking a top to bottom role to adapt to difficulties in wearing condoms. (Adam, et al 2005)

Other “Risk reduction practices” in lieu of wearing condom • assuming the top role with unprotected sex or not ejaculating in the partner) • Pushing the boundaries: (delay in putting it on) Other reasons for not wearing condoms • Momentary lapses: “ heat of the moment” • Trade offs; (a sense of personal neediness, perception of own [un]attractiveness, wish not to spoil the opportunity) • Safe sex requires the person to assert him/herself in the interaction, and it may run contrary to the desire to “give yourself to the partner” (who may be stronger or be in control, taking charge). (Adam, et al 2005)

• Low self-esteem, depression or hopelessness about the future • Current turmoil- generalization and making negative predictions about future • Depression also negatively impacts adherence to antiviral treatment • Disclosure(reliance/trust that partner would say the truth) • HIV + men disclose their status and expect the other to “take the necessary precautions” (Adam, et al 2005)

• Using reported sero-concordance to decide to drop safe sex (PS: superinfection risk or acquiring med- resistant strain of HIV) • Some negative men decide to not wear a condom despite knowing partner is +, sometimes due to a sense of invulnerability after having had a relationship with a + partner without sero-converting- sense of invulnerability • Intuiting safety based on stereotypes or clues (skinny, healthy skin, looking in cabinets for clues of medicine) (Adam, et al 2005)

Condomless sex and relationship building: • “ the most consistent finding in HIV research is the tendency to shift away from safe sex over time” (p 243) • assuming partner is faithful • removing condom presupposes ,expects and conveys trust on/ from the partner • (includes anticipating the relationship will become stable), and decision for monogamy, trying to convey love and commitment to the other. (Adam, et al 2005)

The Impact of Sexual Arousal on Sexual Risk- Taking: A Qualitative Study • 34 gay/bisexual men were called in for in depth interview 20 of them reported having had unprotected sexual encounters they regretted shortly thereafter (after the release of tension post-arousal phase), 35% of the men said they were more likely to engage in risky sexual behavior when aroused that they would later regret; 12% stated they would no longer take any more risks. 2 patterns were identified from men who engaged in risk Bx: • (40%) stated while they remained aware of the risk, they became so aroused to a point where the risk seemed less relevant, (10%) said they were so aroused they did not think of the risk at all. (10%) simply indicated that arousal increased the likelihood of their involvement in the regretted risky encounter. (40%) did not feel that arousal was relevant to their risk management (Strong et al., 2005)

The Impact of Sexual Arousal on Sexual Risk-Taking: A Qualitative Study • Authors compared sexual arousal to having similar effects as of alcohol or fatigue in impairing one’s self-regulation • There are individual differences in inhibitory abilities, including being able to plan ahead and reducing high-risk sexual behavior. (Strong et al., 2005)

Predictors of Sexual Transmission Risk Behaviors Among HIV-Positive Young Men • A substantial number of the men reported serious high- risk behaviors in the past 3 months: • 23% reported never using a condom during sex, 12% did not always reveal their HIV-positive status to sex partners and 6% revealed their status half of the time or less. (Stein et al., 2005, p. 436). • The young men averaged almost 7 sex partners in the past 3 months and almost ¼ of them reported that they never used condoms during sexual acts. (Stein et al., 2005)

Predictors of Sexual Transmission Risk Behaviors Among HIV-Positive Young Men • Only 17% reported that they had not engaged in any sexual behavior in the last three months… • Except for social support and poverty, all of the variables included in our confirmatory model were significantly associated bivariately with highly risky sexual behavior. (Stein et al., 2005, p. 439). • However in the more stringent predictive model, being white, identifying as gay/bisexual, reporting less self- esteem, engaging in delinquent behaviors and using hard drugs predicted risky sexual behaviors (Stein et al., 2005, p. 439). (Stein et al., 2005)

AGE

Young MSM

Youth at Risk • Young people aged 13–29 accounted for 39% of all new HIV infections in 2009. • With regard to youth, HIV disproportionately affects young gay and bisexual men and young African Americans Sexual Risk Factors: -Early age at sexual initiation; unprotected sex; older sex partners. • Male-to-male sex. MSM, especially young African American and young Latino MSM • Sexual abuse. Young adults, both male and female, who have experienced sexual abuse are more likely to engage in sexual or drug-related risk behaviors that could put them at risk for HIV infection.

Sexual Risk Factors- cont • Sexually transmitted infections (STIs). The presence of an STI greatly increases a person's likelihood of acquiring or transmitting HIV. Some of the highest STI rates in the country are among young people, especially young people of minority races and ethnicities. • Substance Use-Young people in the US use alcohol, tobacco, and other drugs at high rates • Lack of Awareness: a large proportion of young people are not concerned about becoming infected with HIV. This lack of awareness can translate into not taking measures that could protect their health.

HIV/AIDS AND OLDER AMERICANS

HIV in Older People • HIV risk does not diminish with age • Persons over the age of 50 may have many of the same risk factors for HIV infection that younger persons have. • -Age-related vaginal thinning and dryness can lead to tears that expose the vaginal area to HIV infection. • Co-infections are common and health deteriorates rapidly • Problems with adherence with med regimen • Older persons may have misconceptions about HIV risks (such as believing that the virus can be transmitted only by blood transfusions or casual contact). • Young clinician may be uncomfortable discussing sex with older pt and vice-versa) and miss the Dx.

Dx Challenges • Testing usually not routine, Dx further along the progression of illness. • Common stereotype: Older people don’t have sex or inject drugs. • But… • Drug users 50 and older were just as likely as younger drug users to engage in risky sexual behavior. • Older persons of minority races/ethnicities may face discrimination and stigma that can lead to • later testing, diagnosis, and reluctance to seek services

HIV in persons 50+ • Dx may be missed and underreported • Some Sx looks like normal aging and are overlooked. • Ex- AIDS-related dementia (misdiagnosed as Alzeimer’s) • Early Sx fatigue, weakness, Wight loss may be considered age-related.

HIV/AIDS and Older Americans • Be alert to possible symptoms. • Physicians may miss a diagnosis of AIDS because some sx can mimic those of normal aging ex: fatigue, weight loss, and mental confusion. • HIV can go undetected in older people because of the symptoms associated with it—such as weight loss, pneumonia and fatigue— also o • Look out for: • ■Cardiovascular disease: • ■Cancer: • ■ Bone problems: • ■Cognitive problems: • ■ Multiple meds- drug interactions

Have the conversation! • Talking to a new partner about their sexual history and HIV, or talking to clinician about sex can be awkward. • Health care professionals may underestimate their older patients’ risk • for HIV/AIDS and may miss opportunities to deliver prevention • messages, offer HIV testing, or make an early diagnosis/ early care. • • older persons may be less knowledgeable about HIV/AIDS and therefore less likely to protect themselves or ask about it. • Older persons of minority races/ethnicities may face discrimination and stigma (delayed testing, diagnosis, and reluctance to seek services)

Drugs and Older Persons • The stigma of HIV/AIDS may be more severe among older persons, leading them to hide their diagnosis from family and friends. • Failure to disclose HIV infection may limit emotional and practical support. • Some older persons inject drugs or smoke crack/ cocaine, which can put them at risk for HIV infection. • HIV transmission through injection drug use accounts for more than 16% of AIDS cases among persons aged 50 and older • HIV test should be routine part of medical care, if having unprotected sex, injecting drugs or have never been tested before. (Medicare covers annual HIV testing. )

OTHER RISKS

Risk factors- Assess: • Individual factors: health beliefs, age, all risk behaviors: sexually active/ IV drugs • Social factors (stigma- MSM internalized homophobia/closeted); age/race (stigma older people may bot discuss sex lives, specially with younger clinician, but due to viagra their sexual activity is increasing) • Interpersonal factors- fear of rejection, locus of responsibility, etc.

Socioeconomic Factors & HIV Risk • Poverty can limit access to health care, HIV testing, and medications that can lower levels of HIV in the blood and help prevent transmission. In addition, those who cannot afford the basics in life may end up in circumstances that increase their HIV risk. • Discrimination, stigma and homophobia: Far too prevalent in many communities, these factors may discourage individuals from seeking testing, prevention, and treatment services. • Prevalence of HIV and other STDs in a community: More people living with HIV or infected with STDs can increase an individual’s risk of infection with every sexual encounter, especially if, within those communities, people select partners who are from the same ethnicity. • Higher rates of undiagnosed/untreated STDs can increase the risk of both acquiring and transmitting HIV. • Higher rates of incarceration among men can disrupt social and sexual networks in the broader community and decrease the number of available partners for women, which can fuel the spread of HIV. • Language barriers and concerns about immigration status present additional prevention challenges.

Other at-risk populations • Injection Drug Users (IDUs): represent 8 % of new HIV infections and 16 % of people currently living with HIV. African Americans account for the greatest numbers of new infections among IDUs. • Transgenders: heavily affected by HIV. A 2008 review of HIV studies on average 28 % tested positive for HIV.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Mortality Mortality Slide Series 2013 Division of HIV/AIDS Prevention

Deaths due to HIV infection are not exactly the same as deaths of persons with AIDS.

Trends in Annual Age-Adjusted* Rate of Death Due to HIV Infection by Sex, United States, 1987−2009 Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules. *Standard: age distribution of 2000 US population

Trends in Annual Rates of Death due to HIV Infection by Age Group, United States, 1987−2009 Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules.

Trends in the Percentage Distribution of Deaths due to HIV Infection by Age Group, United States, 1987−2009 Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules.

Median Age at Death due to HIV Infection United States, 1987–2009 Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules.

Age-Adjusted*AverageAnnual Rate of Death due to HIV Infection by Sex and Race/Ethnicity, United States, 2005−2009 *Standard: age distribution of 2000 US population **Hispanics/Latinos can be of any race The racial/ethnic categories other than Hispanic/Latino are all non-Hispanic/non-Latino

Trends in Annual Rates of Death due to the 9 Leading Causes among Persons 25−44 Years Old, United States, 1987−2009 Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules.

Conclusions After rapidly increasing since the 1980s, the annual rate of death due to HIV infection peaked in 1994 or 1995 (depending on the demographic group), decreased rapidly through 1997, and became nearly level after 1998. Persons dying of HIV infection increasingly consist of:  women (28% in 2009)  blacks/African Americans (56% in 2009)  residents of the South (54% in 2009)  persons 45 years of age or older (63% in 2009) HIV infection remains as one the leading causes of death among persons 25 to 44 years old, particularly among blacks/African Americans.

HIV + Population Issues Clinicians must be aware of: • Disproportionate impact on marginalized groups • Less access to and engagement with care system • Co-morbidities such as hepatitis, mental illness, substance use • Complex psychosocial issues results • Risk behaviors: sexually active/ drugs Assess: • Individual factors: health belief, desirability, age • Social factors (stigma- MSM internalized homophobia/closeted); age/race (stigma older people may bot discuss sex lives, specially with younger clinician) • Interpersonal factors- fear of rejection, locus of responsibility, etc. April 2003

APA • Those on the front lines of HIV prevention and care often struggle with handling clients who are dealing with mental health and substance abuse problems, as well as HIV/AIDS: • Nearly 50 percent screened positive for mental health disorder • Nearly 40 percent reported illicit drug use other than marijuana • More than 12 percent screened positive for drug dependence (Bing et al., 2001) • The APA Office on AIDS has compiled information on this critical topic of co-occurring disorders

Pros-Cons Aspects of HIV/AIDS Positives • More services and support available • Renewed spirituality • New, healthier relationships • Priorities clarified • Conflicts resolved Negatives • Stigma/Discrimination • Estrangement from family/community • Fear of contagion • Fear of death • Feeling like a burden • Loss of dignity • Guilt • Grief over multiple losses April 2003

Cultural Issues • Meaning of illness and death • Family or community role in illness • Value of autonomy • Communication patterns • Mistrust of authority/medical systems April 2003

Interventions • Accompaniment • Advocacy • Assessment • Care Coordination • Crisis Intervention • Engagement • Listening • Motivational Interviewing • Patient/Family Education • Problem Solving • Referrals • Skills Building • Support April 2003

HIV AND MENTAL HEALTH • HIV/ AIDS can affect all aspects of a person’s life. • Pts must adapt to a chronic, life-threatening illness and corresponding physical and mental challenges. • Myriad of emotional demands such as depression, anxiety, cognitive disorders and may have substance-abuse comorbdity. • Substance use and abuse are important factors in the spread of HIV. • • Alcohol and other drugs can lower a person’s inhibitions and create risk factors for HIV transmission. • • Vulnerable populations (people living in poverty, those who are mentally ill, and those with a history of abuse) are more likely to have high rates of alcohol

HIV and CD • Substance abuse is important factors in the spread of HIV. • Alcohol and other drugs can lower a person’s inhibitions and create risk factors for HIV transmission. • Substance use, abuse, and dependence have been closely associated with HIV infection. • Injection drug use (IDU) is a direct route of transmission, drinking, smoking, ingesting, or inhaling drugs such as alcohol, crack cocaine, methamphetamine (“meth”), and amyl nitrite (“poppers”) are also associated with increased risk for HIV infection. These substances may increase HIV risk by reducing users’ inhibitions to engage in risky sexual behavior. • Substance use and addiction are public health concerns for many reasons. In addition to increasing the risk of HIV transmission, substance use can affect people’s overall health and make them more susceptible to HIV infection and, in those already infected with HIV, substance use can hasten disease progression and negatively affect adherence to treatment.

Proven HIV Prevention/ Intervention Methods • HIV testing and linkage to care • Access to condoms • Prevention programs for HIV + and their partners and people at high risk for HIV infection Small groups and community support • Substance abuse treatment and access to sterile syringes

Condom use Campaign • Must address the real reasons men engage in unprotected sex (speak to the audience) “ the link between romantic discourses and willingness to drop condom use is an issue traditionally neglected by HIV-prevention campaigns” (Adam et al ., 2005 pg 247 ) • Problem: past campaigns “ know your partner”- fueled misinformation and misattribution of risk • Clinicians can develop discrepancy using MI between intention and behavior.

Resources for Clinicians • Aids.gov • American Psychological Association The HIV Office for Psychology Education (HOPE) Program www.apa.org/pi/aids/resources/index.aspx • Aids info NIH: http://aidsinfo.nih.gov/education- materials/fact-sheets and Tx guidelines : http://aidsinfo.nih.gov/guidelines/html/1/adult-and- adolescent-arv-guidelines/0 • http://aids.gov/ National Institute of Mental Health: AIDS Research – • UNAIDS: http://www.unaids.org/ (offers data from other world regions)

• HIV Tx guidelines: http://www.hivguidelines.org/clinical- guidelines/hiv-and-mental-health/ • MI for HIV http://www.aidsetc.org/pdf/etres/etres-441.pdf • CDC: CDC HIV/AIDS Homepage • CDC National Prevention Information Network (NPIN): The CDC National AIDS Prevention Information • National Center for Health Statistics page on AIDS/HIV. • Most recent HIV Surveillance Data. • HIV Treatment Guidelines. • AZ Dept of Health Services: http://www.azdhs.gov/phs/hiv/index.htm • http://www.apa.org/pi/lgbt/resources/guidelines.aspx • CDC proven prevention methods • http://www.cdc.gov/nchhstp/newsroom/docs/HIVFactShee ts/Methods-508.pdf

• HIV and mental health: http://www.hivguidelines.org/clinical- guidelines/hiv-and-mental-health/ • Coping with HIV/AIDS: Mental Health: http://hivinsite.ucsf.edu/insite?page=pb-daily-mental • Mental Health & HIV/AIDS: http://www.thebody.com/index/mental.html • Coping with the Psychological Stressors of HIV: Related Resources: http://hivinsite.ucsf.edu/InSite?page=kbr-03-01-05- 01 • HIV Glossary – Compilation of definitions for words commonly used to describe HIV, its pathogenesis, associated treatments, and the medical management of related conditions. Updated in March 1997 to include terms related to recent advances in the field of immunology and the use of combination therapy to manage HIV infection. Also available in Spanish. • AZ HIV Law: http://www.azdhs.gov/phs/hiv/documents/FAQs_HIVProviders.p df http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/ars/3 6/00663.htm&Title=36&DocType=ARS

• Family Health International – Includes a variety of downloadable pdf books on AIDS care, AIDS as a chronic condition and testing. • Healthology: HIV and AIDS – Healthology provides information and articles targeted to people living with HIV/AIDS. Topics are current, extensive, and focus on health, treatment, and daily living. • HIVInSite-Gateway to AIDS Knowledge – Comprehensive, up-to-date information on HIV/AIDS treatment, prevention, and policy from the University of California San Francisco. • HIV InSite – Billed as "the most comprehensive, credible and trustworthy source of online information regarding AIDS," this web site features up-to-date information on medical research, prevention and education, social issues, and community resources. • HIV/AIDS Law and Policy Resource – Designed to provide accurate and authoritative information in regard to HIV law and policy issues. Includes contents of the publication, AIDS and the Law (3rd ed.), authored by David Webber, who created this web site. • International AIDS Society-USA: HIV-Associated Resources on the Internet– Great resource created by Dr. Wendy S. Armstrong and Carlos del Rio published in 2009. • Kaiser Family Foundation (PDF, 340KB) – The Henry J. Kaiser Family Foundation is a non-profit, private operating foundation focusing on the major health care issues facing the nation. KFF develops and runs its own research and communications programs, often in partnership with outside organizations. • Kaiser Daily HIV/AIDS Report – HIV/AIDS report compiled by the Henry J. Kaiser Family Foundation, an independent health care philanthropy. Features current news and reports on policy, statistics, and scientific developments related to HIV/AIDS, both nationally and worldwide. • Kaiser Family Foundation: HIV/AIDS Data & Statistics – Gateway to HIV/AIDS statistics and key data available from the Kaiser Family Foundation, including links to HIV/AIDS fact sheets and state- by-state AIDS and other health-related data. • Life Cycle of HIV Infection (PDF Version, 180KB) – Describes step-by-step process of HIV infection. • Medscape HIV page – Offers links to prominent HIV/AIDS journal, commentary, useful information for both researchers and those affected. • AIDS Education and Training Centers (AETCs) National Resource Center

References • Adam, B., Husbands, W., Murray, J., & Maxwell, J. (2005). AIDS optimism, condom fatigue, or self-esteem? Explaining unsafe sex among gay and bisexual men. Journal of Sex Research, 42, N.3, 238-248. Retrieved from http://www.thefreelibrary.com/AIDS+optimism,+condom+fatigue,+or+self- esteem%3F+Explaining+unsafe+sex+...-a0135380881 • AIDS.gov • Brown, E., Wald, A., Hughes, J., Morrow, R., Krantz, E., Buchbinder, S., ... Celum, C. (2006). High risk of human immunodeficiency virus in men who have sex with men with herpes simplex virus type 2 in the EXPLORE study. American Journal of Epidemology, 164 N.8, 733-741. doi: 10.1093/aje/kwj270 • CDC. (n.d.). WWW.cdc.gov • Department Of Health and Human Services Center for Disease Control and Prevention. (n.d.). HIV and AIDS in the United States: A Picture of Today’s Epidemic. Retrieved June 16th, 2010, from http://www.cdc.gov/hiv/topics/surveillance/united_states.htm • Department of Health and Human Services. (n.d.). HIV Incidence. Retrieved June 16th, 2010, from http://www.cdc.gov/hiv/topics/surveillance/incidence.htm • Stein, J., Rotheram-Borus, M., Swendeman, D., & Milburn, N. (2005). predictors of sexual transmission risk behaviors among HIV-positive young men. AIDS Care, 17(4), 433-442. doi: 10.1080/09540120412331291724 • Strong, D., Carnes, J., Davis, L., & Kennedy, J. (2005). The impact of sexual arousal on sexual risk-taking: A qualitative study. Journal of Sex Research, 42(3). Retrieved from http://web.ebscohost.com/ehost/delivery?vid=7&hid=10&sid=f7c02526-38cf-4fa1-af8a- d1d87110b313%40sessionmgr12

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