Download HIV Infection and Adolescents

HIV Infection and Adolescents
Lawrence B. Friedman, MD
Director, Adolescent Medicine
Objectives
• Review HIV/AIDS statistics and demographics for
US, FL, and world
• Explain basic HIV science facts
• Emphasize affects on children, youth, and young adults
• Highlight HIV care and treatment factors
• Inform about legal issues and testing provisions
• Suggest potential HIV prevention strategies
Human Immunodeficiency Virus
• Discovered by US and French researchers
simultaneously in 1983
• Retrovirus
• Two types (1 & 2)
• Most infections HIV-1, with 5 subtypes (B most
common in North America)
• No cure!
HIV and AIDS in Florida
• Second in nation for adult/adolescent cases
following NY (and recently overtook CA)
• Second in nation for pediatric cases <13
following NY
• Increased number of new cases in seniors and
youth!
Rates of Diagnoses of HIV Infection Among Adolescents Aged
13–19 Years, 2013—United States and 6 Dependent Areas
N = 1,931
Total Rate = 6.5
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 of Diagnoses of HIV Infection Among Young Adults Aged 20–24 Years,
2013—United States and 6 Dependent Areas
N = 8,144
Total Rate = 35.3
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.
1981
First U.S. AIDS cases reported (as Kaposi’s
Sarcoma and Pneumocystis Carinii Pneumonia) in
New York and California.
First case of AIDS reported in Florida.
Florida AIDS case surveillance began through the
Florida Department of Health and Rehabilitative
Services, Disease Control Program.
TOTAL AIDS Cases
United States: 152 cases
Florida: 8 cases
1983
 An AIDS surveillance program was established
within the State Health Office in Florida.
 The Centers for Disease Control declared AIDS a reportable
disease.
 Florida Administrative Code 10D-3 was amended to require
physicians to report diagnosed cases of AIDS to the State
Health Office.
TOTAL AIDS Cases
U.S.: 4,156 cases
Florida: 236 cases
1984
 HTLV-III, later called HIV, was first identified as the
virus that causes AIDS.
 Active surveillance for AIDS cases began in Florida, with
staff assigned primarily in South Florida.
TOTAL AIDS Cases
U.S.: 9,920 cases
Florida: 545 cases
1987
 Florida became the first state to establish voluntary,
confidential HIV counseling and testing services to
all county public health units.
 Specific funding obtained to expand HIV prevention
education to minorities and community-based groups.
 AZT patient care program initiated.
 Up to 3,000 calls a month to the AIDS Hotline.
 AZT (Retrovir) approved.
TOTAL AIDS Cases
U.S.: 59,572 cases
Florida: 3,748 cases
1989
 The “Florida Responds to AIDS” campaign began.
 Project AIDS Care (also known as the Medicaid Waiver
Program) was established.
 FDA authorizes AZT for children.
TOTAL AIDS Cases
U.S.: 115,786 cases
Florida: 9,766 cases
1990
 The Ryan White Comprehensive AIDS Emergency
(CARE) Act was established.
 Evaluation of HIV transmission from health care providers
to patients conducted after a report to the Centers for
Disease Control and Prevention of a Florida patient
contracting HIV from a dentist during the course of
treatment.
TOTAL AIDS Cases
U.S.: 161,073 cases
Florida: 13,487 cases
1994
 Florida awarded $350,000 by CDC to initiate Community
Planning.
 The Florida HIV/AIDS Community Planning Group developed
the first HIV Prevention Plan for Florida.
 Giving AZT to HIV-infected pregnant women would
reduce perinatal transmission by two-thirds.
 Florida AIDS Health Fraud Task Force established.
 FDA approves d4T (ZeritÒ) and OraSureTM saliva HIV test.
TOTAL AIDS Cases
U.S.: 441,528 cases
Florida: 42,166 cases
1997
 HIV infection reporting began in Florida on July 1st.
 The number of persons in the United States living with HIV/AIDS
is estimated at 650,000-900,000 (CDC). The Bureau of
HIV/AIDS estimates that 90,000 Floridians are living with
HIV/AIDS.
 Nelfinavir (Viracept); Delaviridine (Rescriptor); Saquinavir
(Fortovase); and Zidovudine, 300 mg and lamuvidine, 150 mg
(Combivir) introduced as a new protease inhibitor drugs.
 The Bureau of HIV/AIDS held the first Black Leadership
Conference on HIV/AIDS.
Florida HIV Cases: 2,157 cases
TOTAL
U.S.: 619,982 cases
Florida: 62,123 cases
1998
 AIDS Omnibus Act revised, streamlining HIV testing in
the private sector.
 The legislation streamlined HIV testing requirements for
the private sector to encourage the offering of HIV
testing.
 Preliminary planning of the Florida HIV/AIDS Minority Network
initiated.
 The Targeted Outreach for Pregnant Women Act (TOPWA) was
created by the Legislature (s.381.0045, F.S.) to address the high
incidence of perinatally-transmitted HIV and AIDS in Florida.
Florida HIV Cases: 8,946 cases
TOTAL
U.S.: 688,200 cases
Florida: 67,156 cases
2004
 Implementation of rapid HIV testing for pregnant women
initiated in hospital labor and delivery units statewide.
 Rapid HIV testing expanded to 24 sites.
 First Bureau sponsored statewide training for HIV/AIDS Case Managers8 training sites with over 500 participants.
 Behavioral surveillance began.
 Specimen collection for Incidence Surveillance began October 1, 2004.
Florida HIV Cases: 47,373 cases
TOTAL
U.S.: 902,223 cases (2003 data)
Florida: 96,792 cases
2010 U.S. Census
• Estimated 63 million adolescents/young adults ages
10 – 24 years
• 39% non-White
• 17.5% Hispanic or Latino origin
• 15% Black
• 4% Asian/Pacific Islander
• 1% Native American
• 2% Other
LEADING CAUSES OF DEATH
FOR AGES 15 - 24
•
•
•
•
•
•
Accidents
Homicides
Suicides
Malignant Neoplasms
Cardiovascular Diseases
HIV Spectrum of Diseases
Adolescents are:
• Not children
• Not adults
• Childlike in thought and
behavior still
• Adult physically perhaps
• Changing with ongoing
brain development and
cognitive maturation
MILESTONES OF
ADOLESCENT DEVELOPMENT
• Body image concerns/puberty: early adolescence mostly,
cognitive changes begin
• Independence/emancipation: ongoing throughout, risk- taking
during middle adolescence
• Identity formation (including sexual identity): ongoing
• Future orientation/delineation of functional role: late
adolescence mostly, mortality issues, abstract thoughts
PROCESSES ARE UNIVERSAL AND CONSISTENT
Diagnoses of HIV Infection Among Persons Aged 13 Years and
Older, by Sex and Age Group, 2013—United States
and 6 Dependent Areas
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.
Diagnoses of HIV Infection and Population Among
Adolescents Aged 13–19 Years, by Race/Ethnicity
2013—United States
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.
a Hispanics/Latinos can be of any race.
Diagnoses of HIV Infection and Population Among Young
Adults Aged 20–24 Years, by Race/Ethnicity 2013—United
States
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.
a Hispanics/Latinos can be of any race.
Adolescents and Young Adults Aged 13–24 Years Living
with a Diagnosis of HIV Infection, by Sex and Race/Ethnicity,
Year–end 2012—United States and 6 Dependent Areas
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.
a Includes Asian/Pacific Islander legacy cases.
b Hispanics/Latinos can be of any race.
Adolescents and Young Adults Aged 13–24 Years Living with a Diagnosis of
HIV Infection, by Sex and Transmission Category, Year-end 2012—
United States and 6 Dependent Areas
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 and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion,, and risk factor not reported or not identified.
Diagnoses of HIV Infection Among Adolescent and Young Adult
Males, by Age Group and Transmission Category 2013—United
States and 6 Dependent Areas
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 and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Diagnoses of HIV Infection Among Adolescent and Young
Adult Females, by Age Group and Transmission Category
2013—United States and 6 Dependent Areas
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 and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Diagnoses of HIV Infection Among Adolescents and Young
Adults Aged 13-24 Years, by Transmission Category, 2009–2013
United States and 6 Dependent Areas
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 and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Adult HIV Infection Cases, by Sex and
Age Group at Diagnosis,
Reported in 2013, Partnership 11a
Note: HIV infection cases tend to reflect more recent transmission than AIDS cases, and thus present a
more current picture of the epidemic. With regard to the age group with the highest percent of HIV
infection cases, recent estimates show that among males, 29% of HIV infection cases occur among
those aged 20-29, whereas among females 28% of HIV infection cases occur among those aged 50 and
older.
Case Rates* of Adults Living with HIV Disease,
by Sex and Race/Ethnicity,
Reported through 2013, Partnership 11a
RATE RATIOS:
MALES
Blacks:Whites, 2.3:1
Hispanics:Whites, 0.8:1
FEMALES
Black:Whites, 12.6:1
Hispanics:Whites, 1:1
Note: Among black males living with HIV disease reported through 2013, the case rate is 2 times higher than the
rate among white males. Among black females living with HIV disease, the case rate is nearly 13 times higher
than the rate among white females. The Hispanic male rate is lower than the rate among their white counterpart,
whereas the Hispanic female rate is equivalent to the rate among their white counterpart. Data excludes
Department of Corrections cases.
*Source: Population estimates are provided by Florida CHARTS.
**Other includes Asian/Pacific Islanders , Native Alaskans/American Indians and Multi-racial individuals.
Connect to Protect
CASE
• 16 y/o Caribbean Female diagnosed with
pregnancy at JMH Adolescent Clinic, and referred
for Obstetrics care. As part of prenatal screening
exam and ongoing care, she was offered HIV
testing. HIV test was POSITIVE. History
revealed no sexual abuse and only 2 lifetime
sexual partners (22 y/o Haitian male and 21 y/o
Af-Am male).
CASE
• 15-1/2 y/o BM admitted to substance abuse treatment
facility by court order for dual diagnosis. On entry, as
routine, RPR syphilis test was done. It showed 1:32
reactivity, so he was treated with PCN and offered HIV
testing. History revealed by him indicated that he had
two sexual encounters, both with female peers (?). HIV
test was POSITIVE. Parents are both HIV negative, and
he denied ever using injectable drugs.
Primary modes of transmission
for HIV
• Blood
• Sexual fluids
• Mother-to-child
Acute Retroviral Syndrome:
– Onset usually 2-4 wk after exposure
– May resemble infectious mono or flu
– High levels of HIV present in body
– Spontaneous recovery in 1-3 weeks
– Persistent or severe symptoms may not appear
for 10 years or more
Natural Course of HIV Infection and Common Complications
1000
VL
900
CD4+ T cells
CD4+ cell Count
800
Relative level of
Plasma HIV-RNA
700
TB
600
500
400
300
HZV
Acute HIV
infection
syndrome
Asymptomatic
OHL
200
PPE
100
0
OC
TB
CM
CMV, MAC
0 1 2 3 4 5
Months
1
2
3
4
5
6
Years After HIV Infection
7
8
PCP
9
10
11
Defining Exposure:
Infectious Body Fluids
• Definitely infectious:
– blood
– semen
– vaginal secretions
– any visibly-bloody body fluid
Defining Exposure:
Infectious Body Fluids
• Potentially infectious:
–
–
–
–
–
–
–
cerebrospinal fluid
synovial fluid
pleural fluid
peritoneal fluid
pericardial fluid
amniotic fluid
pus
Defining Exposure:
Infectious Body Fluids
• Not infectious, unless visibly bloody:
– feces
– urine
– nasal secretions and sputum
– saliva
– sweat
– tears
– vomitus
Sexual Transmission
• Anal
• Vaginal
• Oral
Risk of Transmission
Probability of infection from single act of
intercourse is < 1.0%, but…
Infection can occur from a single sexual contact.
Transmission may be facilitated by other STDs.
STDs increase HIV infectivity and susceptibility.
HIV Transmission
Any type of unprotected sexual contact
Blood - to - blood contact
Infected female to unborn or newborn child
3 conditions must be met:
 HIV
must be present in body fluid
 Occur in sufficient quantity, and
 Have a portal of entry into bloodstream
Transmission by Contact with
Infected Blood
• Blood
– Shared needles
– Blood and blood
product transfusion
– Organ transplants
– Needle-stick injury
– ? Tattoos/pierces
Substance Abuse and HIV
 Direct transmission from IDU
 Sexual transmission while under the influence, 20 poor
decision making and disinhibition
 Neonatal transmission, 20/mother or mother’s sexual
partner being drug user
 Immunosuppression
 Inability to utilize services
Current Approaches to Treatment of HIV
•
•
•
•
•
•
•
Halt the replication of HIV.
Prevent opportunistic infections.
Treat infections as they occur.
Maintain physical and mental well being.
KISS: Keep It Simple and Safe.
Usual adult PHS/IAS treatment guidelines.
Secondary prevention (including PEP & PrEP)!
Combination Therapy
• Also known as ART
• Known to:
– Slow disease progression
– Improve survival
– Provide greater virologic and
immunologic sustained
response
– Delay viral
mutations/resistance
Health Care Maintenance
•
•
•
•
•
•
•
•
•
Open and non-judgmental approach
Confidentiality, gender neutral questioning
Clearly defined goals of therapy
Interdisciplinary team
Support services
School performance
Hopes/aspirations-school, work, life, children
Immunizations
Growth and development
Psychosocial Issues of Care
•
•
•
•
•
•
•
Substance abuse
Educational needs
Mental health care
Housing
Transportation
Financial assistance
Legal/Juvenile justice involvement
Perinatal Transmission
• Womb
• Delivery
• Breast-feeding
Perinatally Acquired HIV Infected Cases,
Born in Florida, by Year of Birth, 1979-2014,
N=1,220
Birth
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
# % change
21
20
13
15
19
17
11
9
6
3
8
10
6
Note: These data represent a 95% decline in HIV-perinatally infected births from 1993 (N=109) to
2014 (N=6). These data include ALL perinatally acquired HIV Infection cases BORN in Florida.
2014 data are provisional. One of the babies born in 2014 have developed AIDS.
Data as of 06/30/2015.
-5%
-35%
15%
27%
-11%
-35%
-18%
-33%
-50%
167%
25%
-40%
Living Perinatally Acquired
HIV Infection Cases, by County of Birth,
Born in Florida 1979 through 2014
N=833
Number of Cases
0
1 - 10
11 - 25
26 - 50
> 50
A total of 833 perinatally acquired HIV Infection cases born in Florida through 2014 are still
presumed to be alive. The majority (57%) of these cases born in South Florida: Miami-Dade
(N=236), Broward (N=134) and Palm Beach (N=101).
Data as of 06/30/2015
Current Age* Distribution of
Living Perinatally Acquired HIV Infection Cases
by Disease Status, Born in Florida,
1979 through 2014 (N=833)
*Current age of presumed living perinatally acquired HIV Infection cases born in Florida
through 2014.
** The vital status for some of the cases born from 1986 or earlier could not be validated
therefore some of these presumed living cases may be deceased.
Data as of 06/30/2015
ESCAMBIA
HIV Infected Newborns 2007 - 2014
HOLMES
OKALOOSA
JACKSON
SANTA ROSA
WALTON
WASHINGTON
NASSAU
GADSDEN
CALHOUN
JEFFERSON
LEON
HAMILTON
MADISON
BAY
LIBERTY
WAKULLA
DUVAL
BAKER
SUWANNEE
TAYLOR
CLAY
UNION
GULF
FRANKLIN
LAFAYETTE
ALACHUA
DIXIE
ST JOHNS
BRADFORD
PUTNAM
GILCHRIST
FLAGLER
LEVY
MARION
VOLUSIA
LAKE
CITRUS
Number of Cases
Year of Birth
17
2007
2008
9
2009
ORANGE
BREVARD
PASCO
HILLSBOROUGH
11
SEMINOLE
SUMTER
HERNANDO
OSCEOLA
POLK
INDIAN RIVER
MANATEE
OKEECHOBEE
HARDEE
ST LUCIE
6
3
2010
2011
HIGHLANDS
SARASOTA
DESOTO
MARTIN
CHARLOTTE
GLADES
LEE
Data as of 6/30/15
8
2012
10
2013
6
2014
HENDRY
PALM BEACH
BROWARD
COLLIER
MONROE
MIAMI-DADE
SANTA ROSA
8
2
HIV-Exposed Newborns 2014
HOLMES
OKALOOSA
1
1
WALTON
JACKSON
1
WASHINGTON
GADSDEN
1
BAY
NASSAU
9
HAMILTON
LEON
41
MADISON
3
LIBERTY
GULF
WAKULLA
BAKER
SUWANNEE
TAYLOR
FRANKLIN
DUVAL
1
1
UNION
LAFAYETTE
CLAY
1
BRADFORD
ALACHUA
PUTNAM
5
DIXIE
1
2
Infants Exposed to OR Infected
w/ HIV/AIDS
1
MARION
Perinatal HIV Infected  6 (1.2% of
exposed)
Pediatric HIV (not AIDS)  5 cases
•
Duval
• Escambia
• Manatee
• Miami-Dade
• Orange
5
7
LAKE
CITRUS
SUMTER
6
SEMINOLE
4
ORANGE
42
PASCO
HILLSBOROUGH
17
8
15
49
Data as of 06/30/2015
•
Palm Beach
4
OSCEOLA
POLK
INDIAN RIVER
1
MANATEE
2
HARDEE
OKEECHOBEE
ST LUCIE
2
HIGHLANDS
6
SARASOTA
3
4
DESOTO
MARTIN
2
CHARLOTTE
46
LEE
10
2
GLADES
PALM BEACH
HENDRY
BROWARD
COLLIER
1
MONROE
1
Pediatric AIDS 1 case
2
VOLUSIA
HERNANDO
TOTAL Perinatal HIV Exposures
 506
FLAGLER
LEVY
MIAMI-DADE
89
99
STEPS TO PERINATAL SUCCESS
Get Prenatal Care
Keep All Prenatal
Appointments
Get an HIV Test
Follow Up for Mom
And Baby
If HIV+, Maintain
Medication Adherence
Ensure Baby Gets
6-weeks of AZT
STEPS TO PERINATAL SUCCESS, CONTINUED
Counsel Against Breast Feeding
Ensure that Baby
Receives HIV testing
By 4 months
Link to Birth Control if that
Is the Client’s Choice
The Targeted Outreach for Pregnant
Women Act (TOPWA) program.
Collaboration with state agencies and
organizations to ensure that perinatal
HIV issues are addressed.
Perinatal social marketing campaign
on Face Book and Twitter
The Perinatal HIV Program” is located
on the HIV/AIDS and Hepatitis Program
internet site
A Perinatal website through USF that
is widely used
Provide 6-weeks of free AZT for
newborns of families with no medical
coverage
Prolonged Survival--Perinatal
New Complications of HIV?
• Depression
• Feeling of hopelessness
• Loss of family members to HIV
• Overwhelming burden of illness (appointments,
medications, etc.)
• Puberty Issues
•
•
•
•
Short stature, delayed pubertal development
Poor self image
Emotional immaturity/difficulty relating to peers
Sexuality concerns!
Prolonged Survival--Perinatal
New Complications of HIV?
• Increased incidence of cognitive diseases
– Learning disabilities
– Speech problems
– Loss of IQ
• Attention Deficit Disorder
– Poor attention span/concentration
– School failure
– Hyperactivity
Minor’s Consent for
Confidential Health Care
• Evaluation and treatment of sexually transmitted
diseases (includes HIV in most states)
• Family planning, including pregnancy care and
contraception (but not abortion usually)
• Substance abuse attention
• Mental health concerns
• Child abuse/domestic violence/sexual assault exams
Review of Existing Florida Laws
• Minors
– Confidential health care permitted for STDs, family
planning concerns, substance abuse, and mental health
issues (743).
– Minors deemed “mature” do NOT need parental consent
to be tested for HIV (381), since HIV is considered STD
in Florida (384.3).
– Informed consent still for HIV testing, but not required to
be written (2008 revision).
– “Emancipated” minor (743).
VOLUNTARY TESTING
• HIV testing is voluntary, requiring informed
consent.
• All people having the test must be told the
results.
• Exceptions to voluntary testing: Court orders,
federal prisoners, military personnel.
Number and Percentage of HIV-Infected
Persons Aged 13-24 Engaged in Selected Stages of
The Continuum of HIV Care
Miami-Dade County, 2013
(1) Number of cases known to be alive and living in Florida through 2013, regardless where diagnosed, as of 06/30/2014 (used for unmet need calculations).
(2) Ever in Care = 86% of those cases were linked to care, based on persons living with HIV disease in Florida (regardless of where diagnosed) who ever had
a CD4 or Viral load (VL) test in the electronic HIV/AIDS Reporting System (eHARS). (2010 National estimates are 79%*).
(3) 55% of cases were in care this year, based on HRSA unmet need definition, for persons living with HIV in Florida (regardless of where diagnosed) and
having at least 1 HIV-related care service involving either a VL or CD4 test or a refill of HIV-related RX. (2010 National estimates for in care are 56%*).
(4) Estimated 90.6% of In care and on ART this year in Florida per 2011 MMP data (2010 National estimates are 80%*).
(5) Estimated 78.0% on ART & the viral load is <200 this year in Florida per 2011 MMP data (2010 National estimates are 70%*).
*Continuum of HIV care among Ryan White HIV/AIDS Program clients, U.S., 2010 (http://hab.hrsa.gov/data/reports/continuumofcare/index.html)
For additional information please refer to the Florida Continuum of Care slide set accessible at http://www.floridahealth.gov/diseases-andconditions/aids/surveillance/index.html
Improving Prevention for Youth
• Continued school-based risk reduction education (including
abstinence information).
• Encouraging HIV testing (prevention education opportunity).
• Greater efforts to reach out-of-school youth (drop-outs,
homeless/runaway, juvenile offenders).
• Targeted efforts toward young gay/bisexual males, including PrEP.
• Attending to STD treatments and condom availability.
• Assuring Hepatitis B and HPV immunizations.
• Partnering with community-based programs.
• Integrating with substance abuse programs.
• Sustained efforts!
For Florida HIV/AIDS Surveillance Data
Contact: (850) 245-4444
Lorene Maddox, MPH
Tracina Bush, BSW
Julia Fitz, MPH
Ext. 2613
Ext. 2612
Ext. 2373
Internet
http://www.floridaaids.org
Intranet http://dohiws.doh.state.fl.us
CDC’s Internet site for HIV/AIDS Slides:
http://www.cdc.gov/hiv/graphics.htm
RESOURCES
 CDC Website: www.cdc.gov
 HRSA HIV/AIDS Bureau: www.hab.hrsa.gov
 FL DOH: www.floridahealth.gov
 NIH/NIAID: www3.niaid.nih.gov/topics/HIVAIDS/
 Kaiser Family Foundation: www.kff.org
 Advocates for Youth: www.advocatesforyouth.org