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Evaluation of HIV as an Epidemiological Problem

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HIV is a pernicious virus that attacks immune cells known as CD-4 cells, which are a subset of the body’s T cells. The epidemiology of the human immunodeficiency virus in the U.S. has profoundly evolved over the past three decades. Currently, it is a debilitating today that has great demographic diversity, as it impacts persons of all races, ages, sexes, and a myriad of transmission risk behaviors. Experts estimate that at least 50,000 persons will be infected every year, although 20% of those who contract new infections may not actually be aware that they are infected while a considerable portion of persons that know they have the virus do not receive the requisite and proper HIV care (Moore, 2011).

Recently, experts began applying public health principles to the HIV epidemic taking place in the U.S. Community organizations, health departments, and healthcare providers continue to expand targeted testing and HIV screening, which has resulted in a greater proportion of persons infected with HIV becoming aware that they are infected; a decrease in the number of reported new HIV diagnoses; and persons who are infected with HIV living longer. As the epidemic continues to escalate, medical experts have developed more sensitive diagnostic tests, more efficacious medications that have enhanced side-effect profiles, more robust and rigorous confirmation that current treatments blunt the spread of the HIV while improving the health of persons infections, and official documentation of possible benefits of preexposure prophylaxis for individuals who are high-risk. While much progress has been made in terms of identifying those who are at risk for HIV and the treatments provided, the preponderance of persons living with HIV in the U.S. do nor receive antiretroviral treatment.

Furthermore, persons who are infected often do not notify their partners of their condition, while various high-risk behaviors have become quite ubiquitous. While HIV surveillance has unequivocally advanced, targeted and data-driven interventions are not being effectively and celeritously implemented in the majority of geographic locales. More progress can be made if the health care system and public health departments at the local, state, and national levels apply the public health principles. Thereby underscoring the need to integrate public health action and health care.

Background and Significance of the Diseas

In 2012, approximately 1.2 million individuals in the U.S. reported that they were living with the HIV infection, which is a 20% increase from the previous decade due to new infections as well as less deaths related to the acquired immunodeficiency syndrome (AIDS) (Johnson et al, 2014). During the middle of 2008, the Center for Disease Control and Prevention (CDC) published its very first national HIV incidence rates employing a new method that more accurately measures the amount of new infections in the U.S. Predicated on a biological marker of most recent HIV infection, the Centers for Disease Control and Prevention uses a specific way to evaluate the HIV occurrence among individuals who are over the age of 13 in 22 different states in 2006. Based on this method, it was estimated that there were 56,250 new diseases in the U.S.A in 2006, with a 95% confidence interval (Moore, 2006). This estimation does not reflect an escalating HIV incidence; rather, the incidence rate has been relatively stable since the 1990s as a result of highly active antiretroviral therapy which accounts for fewer transmissions of the HIV virus. Nonetheless, the barriers that remain in terms of a declining incidence rate include high-risk behaviors among members of various aggregates that are at risk, delay in presentation for HIV healthcare, and a lack of cognizance of HIV serostatus.

Employing the CDC’s methodology described above, Florida’s HIV Surveillance program estimated that the incidence rate for HIV in Florida in 2010 was approximately 3,454 new HIV infections with a 95% confidence interval 2868-4039. This estimate in 2010 shows a 29.4% decrease in the incidence rate when comparing 2007 and 2010; in 2010, the rate of new infections in the state of Florida was higher than the national rate of 22 for every 100,000 persons. In Miami-Dade County, there are 46.9 new cases per 100,000 population as of the year 2016, or 1,300 new diagnoses on a yearly basis as of 2016.

While the incidence can be measured directly, the overall prevalence of HIV in the United States cannot be since approximately 21% of individuals infected with HIV are undiagnosed. Furthermore, data on national HIV prevalence remain unfinished because the local and state reporting systems for name-based, confidential HIV reported have only been in place since 2008 (Moore, 2006). As Moore (2006) notes, about 80 percent of states that reported HIV cases there was an estimated prevalence of about one million persons in the USA living with the HIV virus (prevalence rate, 450 per 100,000 population.)

In the state of Florida, there are an estimated 106,585 persons who have contracted the HIV virus, wit 72% of those persons being male while 29% of them are female. 46.3% of persons living with HIV in Florida are African American, 23% are Hispanic or Latino, and 29% are white. The rate of persons living with HIV in the year 2015 per 100,000 persons was 615. State public health records show that in 2016, 5000 new diagnoses are made every year; in 2015, 2,055 people diagnosed with HIV die as a result of the virus. There were an estimated 26,000 individuals living with HIV in the county.

Current Surveillance Methods

Surveillance refers to the continuing, organized gathering, examination, interpretation, and distribution of information concerning a health-related event. HIV surveillance stores, examines, and distributes data about new and current cases of HIV infection also involving AIDS. The final surveillance purpose is a nationwide system that syndicates data on HIV infection, disease development, and actions and characteristics of individuals at high risk (CDC, 2016). By achieving this goal, the CDC can funnel funding for HIV prevention to the locales that it is needed the most. The National HIV Surveillance System is the main source for the monitoring and surveillance of HIV trends in the U.S. The CDC allocates funding and other forms of assistance to local and state health departments to collect and analyze the information. All states are required to have name-based reporting of confirmed diagnoses of the HIV infection in addition to those whose HIV infection has developed inti AIDS.

In the state of Florida, the HIV surveillance program plays an integral role in how the state determines the resource needs for HIV in addition to program planning and assessment. Staff working for the state’s HIV surveillance carry out data validation checks to certify that cases are not counted two times in the state or within the national database overseen by the CDC. When duplicate cases are identified within the state, they are merged into one case, which is important since HIV is a chronic condition that calls for infected persons to get tested frequently as a way to monitor successful treatment. It is important to not that persons who have the HIV infection may move in and out of the state of Florida one or more times throughout their life, so cases that are pinpointed as being reported in a different state are subsequently re-assigned from that state’s case. Florida tracks cases of HIV and AIDS by the year that persons receive their diagnosis and by the year that the infection is reported. These years may be different for every case since there are specific stipulations established by the CDC for when an HIV/AIDS case is rendered reportable.

Descriptive Epidemiological Analysis

As the prevalence, incidence, and surveillance methods for HIV have been described above, the epidemiology of HIV in relation to mortality and morbidity has also changed over the past thirty years. Persons living with the HIV are now expected to survive over twenty years, and 40% of individuals who contract HIV will extirpate from a cause that is not related to HIV. As more and more patients are exposed to antiretrovirals, they will continue to live longer with the disease irrespective of their CD4 count. As a result of the improved survival rates among persons infected with HIV, the disease has become viewed as a treatable and chronic condition, which can make prevention efforts and messaging far more arduous to achieve (Deeks, Lewin, & Havlir, 2013). Data derived from the CDC’s database ascertained that an estimated 50% of men who have sex with men engaged in anal intercourse without using protection, and 33% of injected drug users shared needles and syringes, which function as a major barrier to secondary preventative efforts.

There has been much progress in understanding the current HIV epidemic in the United States, yet the care, prevention and treatment remain both demographically and geographically. In terms of geographical disparities, cities like San Francisco, New York, and Washington D.C. still tout some of the highest prevalence and incidence rates, although there has been a small decline in those locales over the past decade. Southern cities in the United States like Atlanta and Miami have witnessed increases in the number of individuals diagnosed with the virus (Miami-Dade County Department of Health, 2014). Such a geographical disparity has been elucidated by Sullivan et al. who developed a program called AIDSVu, which enables users to visualize the HIV epidemic within the context of social determinants of health such as poverty, race, and access to healthcare (AIDSVu, 2015). The emergence of the HIV epidemic in the South can be attributed to issues including elevated sexually transmitted disease prevalence, stigma associated with HIV, and access to the necessary treatment. The capacity to pinpoint these so-called hotspots of continued transmission will be quite useful for funneling resources for prevention effort and towards interventions geared towards thwarting transmission rates.

Ethnic and racial disparities in HIV prevalence and incidence additionally continue to persist, as the data collected by the CDC demonstrate BMSM between the ages of 13 and 24 account for almost 60% of new infections among the aggregate of men who have sex with men. This aggregate continues to be the group that is at the highest risk for contracting HIV since members generally are not aware that they have the infection. Possible explanations for why this group is at risk involve the social determinants of homophobia and stigma, a lack of access to adequate healthcare, unemployment, poverty, other sexual network factors such as high background frequency of STIs and intertwined and small sexual networks. HIV is the most prevalent among African Americans and Hispanics and Latinos, although rates are slowly declining.

Screening and Diagnosis

HIV diagnosis is confirmed by a blood test, oral fluid, and urine, although blood and oral fluid tests are thought to be more accurate; all positive tests must be confirmed with a Western blot. There are several HIV screening tests available in the United States, including HIV Antibody Tests, known as ELISA tests, that can detect antibodies as early as three weeks after a person is exposed. Any positive HIV antibody test must be confirmed with a rapid test known as a Western blot or by an HIV viral load test. Unfortunately, some HIV antibody tests fail to detect HIV-2, which is a strain of the virus that is prevalent in western Africa in addition to some less common strains of HIV-1. The indirect fluorescent antibody test can also detect antibodies created to combat the HIV infection. Like the Western blot screening tool, this test is also used to confirm positive HIV test results.

Plan of Action

One evidence-based, community-level intervention targets black men who have sex with men that is designed to modify social perceptions and norms among members in this aggregate concerning condom use. Targeted social networks have proven to be efficacious in informing how persons view sexual norms and practices. This intervention calls for finding and enlisting opinion leaders and well-respected community members such as a family nurse practitioner who has gained the trust of their peers and are adequately trained in risky sexual norm. It is particularly important to educate members of this aggregate on safe sex and endorse condom use vis-à-vis an ongoing dialogue. According to CDC, this community intervention seeks to diminish the rate of unprotected sex and receptive anal sex; a decrease in the numbers of sexual partners on average; and an increase in condom use among members of this aggregate.

A group-level intervention should target middle-school youths in vulnerable communities to encourage at-risk youths to discuss how their risk behaviors may act as a barrier to them leading successful and fulfilling adult lives. This intervention will be facilitated in a community or school setting by facilitators who have received adequate training. It will involve a 1 session curriculum that will be divided into four parts that will be delivered twice a week over an eight -week period. This intervention involves a randomized behavioral trial of hundreds of Latino and black eighth graders geared towards yield the following outcomes: increase abstinence behaviors; decrease intent to engage in sexual intercourse at a young age; and educate youths on safe sex and where to access information and resources regarding sexual health.

A final intervention will target African-American females in a group-level, peer-led intervention that is supervised by a family nurse practitioner geared towards curtailing sexual risk behaviors among black, teenage females who are sexually active. This intervention provides social skills training for black, female teenagers between the ages of 13 and 19 that enhances their awareness of HIV risk reduction strategies including consistent condom use, abstinence from sex, and having fewer sex partners. The intervention will call for six two hours sessions that peer facilitators and a family nurse practitioner will deliver.

Conclusion

HIV continues to be a national and global epidemic that affects all groups of people, yet the development of antiretrovirals and other treatments have resulted in persons with HIV living longer. Incidence rates have remained relatively stabilized as a result of new medications. Nonetheless, there remain a myriad of disparities and barriers to curtailing the incidence of this potentially fatal condition, included continues stigma, lack of access to necessary healthcare, and other social determinants of health. As a family nurse practitioner, it is important to spearhead group- and community-level interventions that target at-risk persons and disseminate the necessary information and resources so that people are armed with the knowledge regarding how to avoid contracting this condition.

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