The n e w e ng l a n d j o u r na l of m e dic i n e

Medicine a nd So cie t y

Debra Malina, Ph.D., Editor

Applying Public Health Principles to the HIV Epidemic

How Are We Doing?
ThomasR. Frieden, M.D., M.P.H., KathrynE. Foti, M.P.H., and Jonathan Mermin, M.D., M.P.H.

A decade ago, we called for applying public Epidemiolo gic Trends

health principles to the human immunodefi-
ciency virus (HIV) epidemic in the United States.1
Over the past decade, U.S. health departments,
community organizations, and health care pro-
viders have expanded HIV screening and targeted
testing, and as a result a greater proportion of
HIV-infected people are now aware of their in-
fection2,3; the number of reported new diagnoses
of HIV infection has decreased4,5; and people
with HIV infection are living longer.6 We have
more sensitive diagnostic tests; more effective
medications and medications with better side-
effect profiles; rigorous confirmation that treat-
ment prevents the spread of HIV and improves
the health of infected people; and documenta-
tion of the potential benefit of preexposure pro-
phylaxis for some high-risk people.7-12
Despite this progress, most people living with
HIV infection in the United States are not receiv-
ing antiretroviral treatment (ART)3; notification
of partners of infected people remains the excep-
tion rather than the norm; and several high-risk
behaviors have become more common. Anal sex
without a condom has become more common
among gay and bisexual men13 and there appears
to be an increased number of people sharing
needles and other injection paraphernalia.14,15 The
number of new infections has increased among
younger gay and bisexual men, particularly black
men. Although surveillance has improved, data-
driven targeted interventions are not being rapid
ly and effectively implemented in most geo-
graphic areas. Much more progress is possible
through further application of public health
principles by public health departments and the
health care system and, most important, through
closer integration of health care and public health
action.
In 2012, an estimated 1.2 million people in the
United States were living with HIV infection
(Table1)3 an increase of more than 20% over
the previous decade, attributable to continued
new infections and a 36.5% decrease in deaths
related to the acquired immunodeficiency syn-
drome (AIDS).3-5,16,17 Reported new diagnoses of
HIV infection have decreased overall, but there
are large disparities among groups; new HIV
infections are increasingly concentrated among
gay men and younger men. Between 2003 and
2014, the numbers of diagnoses of infections
associated with injection-drug use and hetero-
sexual contact decreased by approximately 70%
and 40%, respectively. However, between 2003
and 2014, diagnoses increased by 5% among all
men who have sex with men, in whom more
than two thirds of all diagnoses now occur, and
more than doubled among young gay and bisex-
ual men.4,5 Blacks continue to account for nearly
half of all diagnoses each year, most among gay
and bisexual men; the proportion of diagnoses
among Hispanic Americans, Asian Americans,
and American Indians or Alaska Natives has
increased, and the number of diagnoses among
people 13 to 24 years of age increased by 43%,
also mostly among gay and bisexual men.18
Behavior s That Incre a se Risk
Anal intercourse without a condom accounts for
the overwhelming majority of infections among
men who have sex with men and a substantial
proportion of infections acquired heterosexually
by women,19,20 and the proportion of gay and
bisexual men engaging in anal sex without a
condom increased between 2005 and 2011.13

n engl j med 373;23nejm.org December 3, 2015 2281

 The n e w e ng l a n d j o u r na l of m e dic i n e

Table 1. Epidemiologic Trends in HIV Infection in the United States, 2003 and 20122014.*

Most Recent Year Percent

Variable Baseline with Available Data Change
Year No. (%) Year No. (%)
Estimated no. of people living with HIV infection 2003 994,000 2012 1,218,400 22.6
No. of deaths among persons who had received 2003 18,347 2013 11,658 36.5
a diagnosis of AIDS
No. of diagnoses of HIV infection
Total 2003 53,106 2014 39,718 25.2
Sex
Male 2003 38,783 (73) 2014 32,185 (81) 17.0
Female 2003 14,323 (27) 2014 7,533 (19) 47.4
Age group
1324 yr 2003 6,193 (12) 2014 8,841 (22) 42.8
2534 yr 2003 14,227 (27) 2014 12,563 (32) 11.7
3544 yr 2003 18,886 (36) 2014 8,011 (20) 57.6
4554 yr 2003 10,044 (19) 2014 6,575 (17) 34.5
55 yr 2003 3,756 (7) 2014 3,728 (9) 0.7
Race or ethnic group
American Indian or Alaska Native 2003 214 (0.4) 2014 205 (1) 4.2
Asian 2003 604 (1) 2014 931 (2) 54.1
Black 2003 25,299 (48) 2014 17,494 (44) 30.9
Hispanic or Latino 2003 10,076 (19) 2014 9,211 (23) 8.6
Native Hawaiian or other Pacific Islander 2003 83 (0.2) 2014 52 (0.1) 37.3
White 2003 15,786 (30) 2014 10,941 (28) 30.7
Multiple races 2003 1,044 (2) 2014 884 (2) 15.3
Transmission category
Male-to-male sexual contact 2003 25,251 (48) 2014 26,612 (67) 5.4
Male, injection-drug use 2003 5,199 (10) 2014 1,424 (4) 72.6
Male-to-male sexual contact and injection-drug use 2003 2,587 (5) 2014 1,111 (3) 57.1
Male, heterosexual contact 2003 5,628 (11) 2014 2,983 (8) 47.0
Female, injection-drug use 2003 3,324 (6) 2014 940 (2) 71.7
Female, heterosexual contact 2003 10,896 (21) 2014 6,556 (17) 39.8

* Data on the estimated number of people living with HIV infection are from the Centers for Disease Control and Pre
vention.3,16 Data on deaths are from the National HIV Surveillance System.5,17 Data on diagnoses of HIV infection are
from the National HIV Surveillance System. Numbers according to transmission category resulted from statistical ad-
justment that accounted for missing data on transmission category. Numbers presented according to transmission
category do not include other and do not sum to the total.4,5
Data on race and ethnic group are from medical-record data reported to the National HIV Surveillance System.

Some gay and bisexual men may believe that
they are having sex only with people of the same
serostatus as theirs, but such assumptions are
often incorrect.21
The rate of opiate addiction has increased in
diverse U.S. populations, and more than 60% of
people who inject drugs report sharing injection
paraphernalia.14 An HIV outbreak in Scott Coun-
ty, Indiana, in 2014 and 2015 associated with
injection use of prescription opiates resulted in
181 cases of HIV infection in less than 12 months
in a town with a population of 4300 one of

2282 n engl j med 373;23nejm.org December 3, 2015

 Medicine and Society

the highest incidence rates ever documented.15 ated with higher viral loads and greater infectiv-
Given increases in opioid prescribing and addic- ity than is long-standing infection.22 Although
tion, many U.S. communities may be vulnerable not yet universally available to health care pro-
to similar outbreaks. viders, the newest tests can identify new infec-
tions within a few weeks after transmission. The
Centers for Disease Control and Prevention
Sur veill ance
(CDC)23 and the U.S. Preventive Services Task
Effective public health action depends on timely, Force24 recommend screening all adults and ado-
accurate, complete surveillance. All jurisdictions lescents for HIV infection at least once, whether
now require name-based HIV reporting. As of or not clinicians perceive that a patient is at risk,
2014, the 42 states (plus the District of Colum- and repeat screening at least annually for people
bia) where approximately 90% of HIV-infected at high risk. CDC guidelines note that sexually
people are thought to live require that all CD4+ active gay and bisexual men may benefit from
T-cell counts and results of viral-load testing be testing as often as every 3 months; regular test-
reported to the health department.3 However, ing can identify infection promptly and facilitate
many health departments do not act on surveil- identification and interruption of transmission
lance results in time to stop transmission, nor chains. Rates of HIV testing have increased over-
do they prioritize collection, analysis, and use of all and particularly among high-risk populations;
data necessary to track and improve critical out- the proportion of high-risk gay and bisexual
comes. Diagnosis of acute HIV infection and men who are aware of their HIV status increased
diagnosis occurring late in the course of infec- from 59% to 77% between 2008 and 2014.
tion represent sentinel health events; the former With increased testing, the number of people
indicates recent transmission, with increased risk estimated to have undiagnosed HIV infection in
of spread, and the latter indicates delayed detec- the United States has decreased by nearly 40%,
tion, with increased risk of premature death. from approximately 250,000 in 20032,16 to approxi-
Immediate reporting by clinicians and laborato- mately 156,000 in 20123 numbers that repre-
ries and rapid investigation, follow-up, and ser- sent 25% and 13%, respectively, of Americans
vice provision to affected persons and communi- living with HIV infection.2,3 But the proportion
ties should be, but is not yet, the standard is more than 40% among 18-to-24-year-olds and
response. more than 25% among 25-to-34-year-olds.3 The
Investigations that use molecular epidemiol- proportion of people who received a diagnosis of
ogy can help identify chains of transmission that HIV infection late in the course of their infection
can be interrupted by ART. Even without molecu- (i.e., in whom AIDS developed within 3 months
lar epidemiologic evidence, prompt diagnosis, after the diagnosis of HIV infection) has de-
case interviews, and partner services can provide creased by nearly 30% since 2003,3,25 although
sufficient information for action. Use of tradi- more than 20% of people who received a diagno-
tional and new data sources including data sis of HIV infection in 2013 received the diag-
on diagnoses of HIV infection, primary and nosis late.3
secondary syphilis cases, rectal gonorrhea cases,
rectal chlamydial infections, and indicators of
Par tner Notific ation
injection-drug use, as well as social media and
(if patient confidentiality is safeguarded) elec- A core intervention to stop transmission of com-
tronic health records can help in identifying municable disease is the identification, notifica-
and stopping microepidemics. tion, counseling, and testing of partners, with
prompt linkage of infected partners to treatment
in order to both improve their health and reduce
C a se De tec tion
further transmission. Partner services identify
Health departments and clinicians have made people with undiagnosed or diagnosed HIV infec-
considerable progress in improving early diag- tion who are not receiving care. Health depart-
nosis of HIV infection. More sensitive laboratory ments play a key role in partner services: as
tests make earlier detection possible and permit compared with health care providers, disease-
diagnosis of acute HIV infection,7 which is associ- investigation specialists in the New York City

n engl j med 373;23nejm.org December 3, 2015 2283

 The n e w e ng l a n d j o u r na l
100
Overall People 1824 yr of age
90 87
Percentage of HIV-Infected People
80
70
60 56
50
39
40 36
30
30 26
21
20
10
0 (Fig.1).3
Received a Received Care Were Prescribed Had Viral
Diagnosis ART Suppression
Figure 1. Percentage of HIV-Infected People at Each Stage of the HIV Care
Continuum, United States and Puerto Rico, 2012.
National HIV Surveillance System data were used to estimate the number
of people 13 years of age or older who were living with diagnosed or undiag-
nosed HIV infection (prevalence) in the United States at the end of 2012.
Data from the Medical Monitoring Project were used to estimate the number
of people 18 years of age or older who received medical care for HIV infec-
tion between January and April 2012, the number who received prescriptions
for antiretroviral treatment (ART), and the number whose most recent viral
load in the previous year was undetectable or less than 200 copies per milli-
liter.
Health Department elicited information about
partners from a higher proportion of index-case
patients (51% vs. 18%), elicited information
about more partners per patient (0.87 vs. 0.22),
and notified a higher proportion of named part-
ners (70% vs. 48%).26
Despite the importance of these services, in-
terviews to elicit names and contact information
of partners were documented to have been con-
ducted with only about half the people who re-
ceived a diagnosis of HIV infection in 2014, and
patients who named partners named relatively
few. Although increasing the number of part-
ners named, tested, and linked to services can
be difficult, especially in the context of anony-
mous sexual encounters, partner notification and
testing of people in patients social networks, in
part through the use of Internet and mobile
technology (with appropriate safeguards), can
help public health, clinical, and community-
outreach workers find newly infected and highly
infectious people and get them treatment, im-
prove their health, and stop transmission.27
2284 n engl j med 373;23nejm.org December 3, 2015
of m e dic i n e
Tre atment
Effective public health and clinical programs are
accountable for outcomes of the treatment of
every patient.28 On the basis of randomized,
controlled studies, guidelines for the treatment
of HIV infection now recommend ART for all
HIV-infected people.8 Treatment, ideally leading
to viral-load suppression, benefits the infected
person and interrupts transmission, but in 2012,
only an estimated 39% of HIV-infected people in
the United States were receiving medical care
16
for HIV infection, 36% had been prescribed ART,
and 30% had documented viral suppression
Although rates of treatment and viral sup-
pression are improving and documented rates
may underestimate actual rates,29 hundreds of
thousands of people with diagnosed HIV infec-
tion are not receiving care or ART; these people
account for most new HIV transmissions in the
United States (Fig.2). The greatest loss of patients
in the HIV continuum of care occurs between
diagnosis and engagement in medical care. Up-
dating of published estimates30 suggests that it is
likely that more than 90% of transmission cur-
rently comes from people with diagnosed infec-
tion who are not retained in care (69%) and people
whose infection has not been diagnosed (23%).
For uninfected persons who engage in high-
risk behavior, ART (preexposure prophylaxis) can
substantially reduce the risk of acquiring HIV
infection through sexual or needle exposure31;
its effectiveness correlates directly with the level
of adherence.12 Preexposure prophylaxis is likely
to have the greatest effect among people at very
high risk for infection, among whom the num-
ber who need to be treated for 1 year to prevent
one HIV infection may be as low as 13.32
Applying Public He alth Principle s
Core interventions for the control of communica-
ble disease are prompt diagnosis, systematic part-
ner notification and follow-up, and accountability
for treatment of all patients. Working together,
health care providers, clinical systems, and public
health and community organizations can iden-
tify people with newly and previously diagnosed
HIV infection, provide care and ART as soon as
possible with the goal of suppressing their viral
load, and keep them in care continuously.
 Medicine and Society
An estimated 45,000 new HIV infections oc-
cur each year in the United States, about 30,000
transmitted by patients with diagnosed infection
who are not receiving care and about 10,000 by
people with undiagnosed infection (Fig.2). It is
possible to improve early diagnosis further by
implementing intensive testing (particularly in
demographic and geographic groups with recent
transmission), improving partner notification,
and testing people in the social networks of HIV-
infected people. With improvements in detection
over the past decade, it is now even more impor-
tant to improve rates of initiation and continua-
tion of treatment to fill the biggest current
gap in the care continuum and reduce transmis-
sion substantially. Targeted preexposure prophy-
laxis in people at highest risk can further reduce
the number of new infections.
We now know that treatment of HIV infection
is most effective when started early and contin-
ued throughout life but face challenges that are
familiar from other chronic, often asymptomatic
diseases: patients who feel relatively well are
reluctant to initiate or continue treatment that
may have or be perceived to have adverse effects.
The situation is further complicated by the stigma
associated with HIV infection and HIV risk
behaviors and the disproportionate social, drug-
addiction, and economic challenges faced by
people living with HIV infection.
Jurisdictions throughout the United States and
elsewhere33 that have implemented public health
principles have documented encouraging prog-
ress in reducing new infections. San Francisco,
for example, increased rates of testing (including
for recent and acute infection), partner notifica-
tion, linkage or reengagement in care, and treat-
ment of all HIV-infected people; as a result, viro-
logic suppression has been achieved in a greater
proportion of HIV-infected patients.34-38 These
initiatives plus preexposure prophylaxis were
associated with a 40% decrease in reported new
infections between 2006 and 2014, even though
the rate of condomless sex among gay and bi-
sexual men remained high and may have in-
creased.39 The New York City Health Department
provides individual-level support to link patients
to treatment and reengages patients who are not
receiving care to reinitiate ART.40,41 Rates of viral-
load suppression have increased steadily, and be-
tween 2006 and 2013, the number of reported
new infections decreased by 32%.40,42
n engl j med 373;23nejm.org December 3, 2015
100 3
3 People with viral
2 suppression
90
People prescribed ART
30
80 without viral suppression
People receiving care but
70 not prescribed ART
6
3 People with diagnosis
60 and not receiving care
Percentage
69
50 People with undiagnosed
HIV infection
40
48
30
20
10 23
13
0
People Living with Transmissions
HIV Infection
Figure 2. Percentage of People Living with HIV and Percentage of HIV
Transmissions at Each Stage of the Care Continuum, United States
and Puerto Rico, 2012.
National HIV Surveillance System data were used to estimate the number
of people 13 years of age or older who were living with diagnosed or undi-
agnosed HIV infection (prevalence) in the United States at the end of 2012.
Data from the Medical Monitoring Project were used to estimate the num-
ber of people 18 years of age or older who received medical care for HIV in-
fection between January and April 2012, the number who received prescrip-
tions for ART, and the number whose most recent viral load in the previous
year was undetectable or less than 200 copies per milliliter. The percentage
of transmissions from each group was estimated by applying transmission
rates from Skarbinski et al.30 to 2012 surveillance data. There were about
10,000 transmissions from people with undiagnosed HIV infection, 31,000
from those with diagnosed infection who were not in care, 900 from those
in care but not prescribed ART, 1300 from those prescribed ART but with-
out viral suppression, and 1500 from those with viral suppression.
Conclusions
Scientific and policy advances over the past de-
cade have provided more effective tools for pre-
venting HIV infection and improving outcomes
among infected people. The challenge now is to
increase integration of health care and public
health efforts in order to use these new tools to
greatly reduce new infections (see the Supple-
mentary Appendix, available with the full text of
this article at NEJM.org). Momentum has been
generated by the recently updated National HIV/
AIDS Strategy, which includes a goal of viral-
load suppression in 80% of people with diag-
nosed infection, an executive order to improve
the continuum of care, increased access to
health insurance coverage through the Afford-
able Care Act, and a global focus on detection,
treatment, and viral-load suppression.43-45
2285
 The n e w e ng l a n d j o u r na l
Advocacy by and for people living with HIV
infection has accelerated drug development and
approval and empowered patients and communi-
ties. Increasingly, public health principles are be-
ing implemented to stop the HIV epidemic, and
the rate of new infections appears to be declining
despite the facts that more people are living with
HIV infection and that rates of high-risk behav-
iors are stable or increasing. Yet much more needs
to be done, such as increased use of testing,
including of the partners of infected people and
others in their social networks to rapidly identify
recent infections; targeted preexposure prophy-
laxis for key high-risk groups; and, most impor-
tant, treatment initiation, continuation, or re-
sumption in many more infected people.
The combination of patient empowerment,
community engagement, clinical excellence, and
public health focus on outcomes and impact
could make management of HIV infection a
model for combating other chronic diseases. In
another 10 years, scientific advances and further
implementation of public health principles could
substantially reduce the number of new HIV in-
fections in the United States.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Karen F. Brudney, M.D., Moupali Das, M.D., M.P.H.,
Samuel Dooley, M.D., and H. Irene Hall, Ph.D., for assistance
and review of the manuscript, and Anna Satcher Johnson, M.P.H.,
Gabriela Paz-Bailey, M.D., Ph.D., and Michele Rorie, Dr.P.H.,
M.P.A., for assistance with data analysis.
From the Centers for Disease Control and Prevention, Atlanta.
This article was published on December 1, 2015, at NEJM.org.
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