This month, Medical News takes a closer look at HIV (human immunodeficiency virus) in Kentucky. According to Julia Richerson, MD, with the Family Health Centers in Louisville, Ky., rates are on the rise and there is a lot of work being done, both here and across the state, to address it. Richerson stressed the urgency of raising awareness about testing and prevention within the provider community. We reached out to some local experts to get the facts. Highlights are below.

Medical News: How common is HIV in Louisville? In Louisville (Jefferson County) is the rate rising? What role does the opioid epidemic play in rates? Who is at risk?

In Jefferson County, we have had 4,524 total HIV cases in the past 10.5 years, with 2,916 people living with HIV disease in Jefferson county through June of 2017. Jefferson County remains the county with the highest number of HIV rates. KPIDA/North Central Region (consists of Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer and Trimble counties) is the highest area for HIV in the state and represents 48 percent of cumulative HIV diagnoses in Kentucky.

The estimated annual HIV disease diagnosis rate in Kentucky is 7.6 per 100,000, which ranks 26th in the nation. However, in Jefferson county, this is higher. In 2016, the number of newly diagnosed HIV cases was 147 and the diagnosis rates was 14.7 per 100,000 (we would rank tenth in the nation if we were a state).  We have not seen a significant increase in HIV cases since 2013, which is likely in part due to our robust syringe exchange program in Jefferson county.

A county-based risk factor report is not available, however, in Kentucky, there appears to be a disparity in heterosexual black women (who make up 47 percent of new cases in women compared to 44 percent of new cases in white women) as well as black men (30 percent of newly diagnosed cases in males are in black men compared to 64 percent in white men).

Fifty-six percent of cases in Kentucky have been diagnosed in men who have sex with men (MSM). Ten percent of cases in Kentucky have been contracted through intravenous drug use (IDU). Five percent have been in both. 14 percent of cases have been via heterosexual contact, with three percent in females via heterosexual contact. This data is from 2007 to 2017.

Medical News: What is Pre-exposure Prophylaxis (PrEP) for people at risk? Where can people receive this care? Can HIV be prevented?

PrEP is a Pre-exposure Prophylaxis that reduces the risk of HIV. As there is not a cure for HIV, this is designed to assist in preventing HIV in individuals who are at a substantial risk of exposure such as persons who inject drugs (PWID’s), are gay or bisexual men, have three or more sexual partners a year, have sex without condoms, have been in jail or prison or have had a sexually transmitted infection.

Current studies show that with proper use of PrEP, HIV transmission can be decreased by 70 percent in persons who inject drugs (PWID’s) and by 92 percent in persons who have unprotected sex.

The treatment regimen is quite simple, one pill once a day. That’s it and it can significantly diminish the transmission rate of HIV for persons 18 and over. There are several places locally to receive this care such as some primary care practices, Norton Infectious Disease Specialists, the 550 Clinic at the University of Louisville and even Walgreens has opened specialty clinics around Louisville to assist with PrEP.

For those that are on PrEP it is very important to follow up with their prescribing doctor every three months to have repeat HIV testing as this is a concern. While Truvada is recommended for PrEP, it is not recommended for HIV positive patients. Most insurances will cover PrEP and Norton’s has a specialty pharmacy geared towards providing prior authorization assistance with insurance companies and financial assistance for those in need.

If you can prevent a life altering disease, why not do it? It is as simple as taking one pill a day and seeing your doctor every three months. It is a small ask for such a large reward.

Medical News: How important is increasing screening to decrease the rate of HIV? Where can people get tested? 

Routine screening for HIV raises awareness to medical providers and patients that we must talk about HIV and know our HIV status no matter who we are. With increased routine screening, it will allow HIV prevention to be discussed more freely and routinely by medical providers and patients. Safe sex practices and other methods of HIV prevention are paramount, but routine HIV screening will also help detect and identify patients with the virus earlier which will greatly improve mortality and morbidity rates for those newly diagnosed with HIV.

Increased screening of HIV will help bring sexual health discussion into normal protected medical care discussions with patients. Anyone 13-64 years old should be offered an HIV test regardless of his or her sexual risk behavior.

Just ask the patient, “Would you like an HIV test today?” and let them know you offer it to everyone equally regardless of sexual behavior.

Discussing HIV test results openly with the medial provider allows one to take charge of their sexual health and feel confident in the testing performed. When you know your status regarding all sexually transmitted infections you are more aware of what you are doing and more inclined to use condoms and practice safer sex.

Healthcare providers should openly offer HIV testing to their patients and patients should be asking their medical providers to order the test if they are not being offered.

Family practice, primary care, obstetrics and gynecology, pediatricians, infections disease, adult or geriatric, urgent care providers and emergency departments providers should all have access or be able to guide a patient to a provider who can order and interpret an HIV test.

Many other organizations that are clinical and non-clinical sites like Ryan White, Volunteers of America, local health departments, university health clinics, Planned Parenthoods, some Walgreens and some dental practices offer HIV screening tests as well. On-line tests for HIV are also available.

An HIV test is obtained by a blood draw, finger prick or oral mouth swab. The serum blood test is done in a laboratory and will take 24 to 48 hours for results. Rapid tests such as the oral mouth swab or finger prick blood test will generally provide testing results within the hour.

Medical News: Is there still stigma in the general community and health community around HIV? What can we do to decrease stigma?

Stigma around HIV is one of the biggest barriers to addressing this epidemic. Stigma can get in the way of prevention, HIV testing, going to the doctor and staying consistent with medication. Stigma also impacts mental health, social support and quality of life for people living with HIV. All of these are important for not only long-term survival for people living with HIV, but also for preventing transmission to others.

Although we have learned a lot about HIV since its discovery and therapies have drastically improved survival prospects, there remains a great deal of fear and misinformation about the disease.

In that vein, social climate is one of the most notable factors impacting HIV-related stigma. Stigma thrives in environments of misinformation, myths and marginalization. For example, HIV-related stigma can persist because of a lack of education. This is especially true when there is a lack of information on HIV transmission.

Unreasonable fears of HIV positive individuals can flourish because of unnecessary hypervigilance around casual contact. Alternatively, stigma decreases when there is accurate widespread information about HIV, resources for prevention and access to culturally-competent healthcare.

Thus, the fight against HIV-related stigma includes efforts to promote evidenced-based HIV-focused education, egalitarian healthcare policies and inclusive healthcare delivery.

Medical News: What are opportunities for preventing HIV in adolescents?

HIV infection transmission is a child health issue. According to the 2016 Kentucky HIV/AIDS Surveillance Report, the number of new cases reported in children ages 13 to 19 was 375 and for ages 20 to 29 was 3,028. These two age groups accounted for 34 percent of all newly diagnosed cases.

And according to the CDC, about 14 percent of those infected with HIV are unaware. This could account for the rapid rise of diagnoses between these two age groups.

Healthcare providers who serve children and young adults play a significant role in stopping the spread of HIV. Education, screening and prescribing Pre-exposure Prophylaxis (PrEP) should be the standard of care we provide. However, routine screening is not always performed. PrEP is a new prevention option for children 70 kg and over that many child health providers are not aware of.

The AAP and the CDC recommend screening for all children, not only those at high risk. The CDC recommends opt out testing for everyone age 13 and older. The AAP currently recommends offering testing to all youth once by age 16 to 18, and annually for high risk youth.

The crucial step that child health providers must take is to test. Opt-out, routine testing should be our standard of care. Taking comprehensive sexual histories is also essential and using the CDC’s “5 P’s Guide to Taking a Sexual History” creates a standardized approach we can all do.

Medical News: Where do people obtain care if they are diagnosed with HIV?

Elwood Stroder, Co-Director, Ryan White Part B Services, University of Louisville 550 Clinic: In the Louisville Metropolitan Area there are several places where one can access HIV care.

Medical News: What community resources are available to people living with HIV        

A silver lining regarding HIV can be found in the availability of resources:

Volunteers of America Mid-States

• • Prevention Case Management – Assists individuals with their diagnosis, helping with medication adherence, disclosure and can attend medical appointments
  • Mobile Syringe Exchange Program – Operates in the community four days per week
• House of Ruth
  • Residential substance use treatment (Glade House)
  • Long term HOPWA housing
  • Food pantry
  • Clothing closet
  • Transportation assistance
• University of Louisville KCCP Program and 550 Clinic
  • Medical services
  • Case management and enrollment into ADAP program to assist with medical costs
  • Transportation assistance
  • Support groups
  • Dental services
• Clark County Health Department/Hoosier Hills
  • Medical services
  • Addiction recovery services
  • Housing assistance
• Legal AID Society
  • To qualify for direct legal representation, a client’s income ordinarily must be at or below 125 percent of current federal poverty guidelines

SCREENING RESOURCES
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm\

https://www.cdc.gov/hiv/testing/nonclinical/index.html

https://www.cdc.gov/hiv/testing/hometests.html

PREVENTION RESOURCES

https://www.cdc.gov/std/treatment/sexualhistory.pdf

https://chfs.ky.gov/agencies/dph/dehp/hab/Documents/AnnualReport_2016.pdf

https://www.aap.org/en-us/Documents/periodicity_schedule.pdf