In 2022, the HIV epidemic and Mpox outbreak collided, causing GNR Public Health to quickly coordinate and implement vaccination response efforts, including redirecting programmatic staff and organizational efforts, efforts already stretched to capacity as a result of the COVID-19 pandemic. While already faced with capacity challenges in addressing the HIV epidemic, and while recovering from an extensive COVID-19 response, the Mpox outbreak further magnified response and community protection challenges. In light of those challenges, as GNR Public Health mobilized our response, a strategic and innovative approach was required to maximize efforts, and greatly impact communities served by GNR Public Health. Strategies to address both public health emergency and ongoing HIV prevention priorities were vitally necessary. Practices were developed to ensure a collaborative and coordinated response effort and to ensure our response prioritized equitable access to both Mpox vaccine and prevention services, all with a very short response window and a high demand for vaccine. With both public health concerns at the forefront, a collaborative plan to tackle both issues was a dire necessity.
To understand the significance of GNR Public Health's (GNR) approach, it is first important to understand the observed impact of the Mpox outbreak and HIV epidemic. In May of 2022, Mpox cases hit the U.S., with a significant increase in cases being observed, causing concern both globally and domestically. Currently, as of December 2022, there have been 29,630 Mpox cases in the U.S, and similar to what's been seen with the HIV epidemic, the Mpox outbreak has disproportionately affected certain subpopulations. Among U.S. Mpox cases, 99% have occurred in men, with 94% of whom reported engagement in recent male to male sexual or close intimate contact. According to the Centers of Disease Control and Prevention (CDC), as of November 30, 2022, it reported that 41% of reported Mpox cases are Black or African American, 31% are White and 10% are Hispanic. The racial/ethnic disparities observed nationally have also been observed in the state of Georgia, and according to the December 28, 2022, Georgia Mpox Situational Report, males accounted for 97% of positive probable and confirmed Mpox cases, and Black/African Americans accounted for 77% on new cases, with a significant number of cases identifying as men who have sex with men (MSM), and as HIV positive. In addition to the observed Mpox disparities by gender and race/ethnicity, Georgia was identified as one of the top five states with the highest Mpox cases.
Evaluating the populations being disproportionately affected by the Mpox outbreak, GNR Public Health identified major similarities between the populations being disproportionately impacted by the HIV epidemic. Despite continued efforts and progress made in combatting the HIV epidemic, the epidemic has continued to have a drastic toll in the U.S. Despite the infusion of significant financial resources across the nation, there has not been a significant decline in the number of newly diagnosed cases. From 2016 to 2019, HIV diagnosis decreased 8% overall in the US and dependent areas (cdc.gov/hiv/statistics/overview/ataglance.html). In 2020, 30,635 people received an HIV diagnosis in the United States and dependent areas. Of the 30,635 newly diagnosed HIV cases, Black/African Americans accounted for 12,827 of the cases, Hispanic/Latino accounted for 7,999 cases, and White individuals accounted for 7,831 cases, with male to male sexual contact accounted for 20,758 of cases. (cdc.gov/hiv/statistics/overview/ataglance.html). In Georgia, according to 2019 DPH HIV surveillance data, 79% of those diagnosed with HIV infection were male, and among males, 83% were attributed to male to male (MSM) sexual contact, and 71% of cases were among Blacks, and the rate of diagnosis was highest among Blacks.
In 2019, an effort to more strategically address the HIV epidemic, the U.S Department of Health and Human Services (HHS) launched the Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the U.S. by 90% by 2030, by scaling up key HIV prevention and treatment strategies. At the heart of the initiative, is the determination of leveraging innovative HIV prevention tools, and implementing a community driven approach that focuses on diagnosis, prevention, treatment and outbreak response. This strategic focus ensures increased testing accessibility and availability, leading in an increase in individuals knowing their HIV status, while also ensuring individuals with a negative HIV status are provided HIV prevention education, assessed for PrEP eligibility, and appropriately linked to PrEP services. In addition, testing ensures HIV positive identified individuals are rapidly linked to HIV care services. The initial phase of the initiative focuses on 57 priority jurisdictions that account for more than half of new HIV diagnoses, with Gwinnett County being designated as one of those jurisdictions. This designation has afforded GNR Public Health the opportunity to receive additional funding to address the growing HIV epidemic, working collaboratively with other EHE jurisdictions throughout metropolitan Atlanta.
Therefore, recognizing observed commonalities in the communities being disproportionately impacted by the Mpox outbreak and the HIV epidemic, GNR Public Health's goal was to continue the task of meeting people where they are, while also ensuring that those most impacted, and marginalized communities have equitable access to Mpox vaccine and HIV prevention services. Working collaboratively with trusted HIV Care providers, community partners and community advocates, GNR Public Health strive to accomplish this goal, while also working diligently to ensure that GNR Public Health break the chain of transmission in all vulnerable populations. This practice has been accomplished through strategic planning and collaboration, and taking the opportunity to integrate HIV prevention wrap around services into Mpox vaccination response efforts. Integration of HIV Prevention wrap around services with Mpox vaccination efforts enhance ongoing Ending the HIV Epidemic initiatives in Gwinnett County, GA.
Initially, Mpox vaccine demand far surpassed vaccine availability in Gwinnett and surrounding metro Atlanta counties. Due to limitations in vaccine supply, and to ensure care was provided in an environment trusted by the identified at-risk population, initial appointment only events were facilitated in partnership with a trusted HIV care organization in Gwinnett County. In the initial phase of Mpox vaccine rollout, GNR Public Health observed that many of the individuals arriving for appointments did not mirror the populations being disproportionately affected by the outbreak. Even though GNR Public Health desired to ensure vaccine availability to all vulnerable populations, we were cognizant of the need to engage disparate communities. Therefore, in an effort to ensure vaccine equity, GNR Public Health partnered with community based organizations, and funded EHE partners that serve high risk, minority populations, to ensure vaccine appointment availability was prioritized for these communities. In addition, GNR Public Health collaborated with minority community advocates who were able to more efficiently communicate within their social networks, encouraging the Mpox vaccine, and sharing vaccine appointment availabilities. Some advocates even took the initiative to assist their community with registering for available appointments. These efforts assisted with ensuring equitable vaccine distribution, so GNR Public Health could get the vaccine into the arm of the most impacted communities.
As a result of our efforts to ensure vaccine equity, during our initial response in July 2022, 64% of Mpox vaccine recipients among White and 27% among Black populations, compared to 48% among White and 43% among Black populations in September 2022; 41% of overall vaccine recipients in 2022 were Black. In addition to ensuring equitable vaccine administration, GNR Public Health ensured that vaccine education was offered in multiple languages and ensured translators were present at all vaccine events. GNR Public Health also ensured media messaging targeted at-risk audiences. As vaccine availability increased, strategies were implemented to increase availability, including daily appointments in multiple locations, including GNR District Health Office, Health Department clinics, and utilization of large-scale drive thru/walk-in events. GNR Public Health also ensured all clients had access to wrap around HIV prevention services.
HIV prevention wrap around services include, providing rapid point of care HIV testing, distributing at home HIV test kits, PrEP referrals and linkage, linkage to HIV Care, enrollment in condom subscription program, connecting clients with their local health departments, if needed, and providing STI/HIV/Mpox prevention education. These efforts were prioritized in all GNR Public Health Mpox vaccination efforts. Our goal was to ensure all individuals were aware of their HIV status prior to leaving vaccination event, therefore, rapid point of care HIV testing was offered to all clients. All testing and prevention education was implemented by HIV and STD prevention program staff. Clients with negative test results were provided prevention education, including PrEP education, and clients with positive results were rapidly linked to HIV care services. Clients voluntarily disclosing their HIV positive status were linked and reengaged if reported to be out of care. Home HIV test kits were also offered to clients for self-utilization and/or to distribute among their social network. Clients interested in home test kits were encouraged to access a QR code and complete a short survey. The QR code also linked individuals to GNR's HIV Prevention website, www.SURGEGNR.com. In an effort to provide ongoing support, clients utilizing at-home test kits were encouraged to contact the HIV Prevention team for assistance if they had any testing questions or concerns. PrEP referrals and direct linkage to PrEP services were also provided, with some clients being linked to same day services. Lastly, interested clients were enrolled in our free mail order condom subscription program, which provided access to 30 free condoms every three months.
In taking this strategic approach to provide equitable vaccine and HIV prevention wrap around services, from July 10, 2022 to December 15, 2022, 7,493 Jynneos vaccines were administered, 732 rapid HIV tests were administered, 633 home HIV test kits were distributed, and 118 patients were enrolled in PrEP; 10 individuals were diagnosed and linked to care. This innovative approach was vital and instrumental in combatting both the Mpox outbreak and HIV epidemic, and provided a needed opportunity to engage with communities that historically have been challenging to engage, especially recognizing that many vulnerable populations may fail to utilize traditional route of accessing the healthcare system, due to stigma and structural barriers to care. This innovative approach allowed GNR Public Health the opportunity to coordinate, mobilize and deploy staff across multiple GNR Public Health programs, staff that worked closely and collaboratively, thereby, increasing our capacity to response to multiple public health emergencies simultaneously, including COVID 19, HIV and Mpox.
Looking forward, GNR Public Health will continue working diligently to integrate HIV prevention services into programmatic functionality, ensuring increased HIV testing access and availability in the community, increased prevention education, and provide linkage to PrEP and HIV care services. In addition, as GNR Public Health strives to continue providing the aforementioned, GNR Public Health will continue developing and strengthening community partnership, and working collaboratively with other EHE jurisdictions, in an effort to blur jurisdictional line, as GNR Public Health understand infectious diseases knows no boundary, including HIV. GNR Public Health will continue to prioritize this practice as GNR Public Health strive to greatly impact the community GNR Public Health serve and End the HIV Epidemic. The integration of HIV prevention activities into emergency response activities presents a model of integrated functionality where silos associated with traditional Public Health response and finding are broken down to ensure that GNR Public Health are serving the population with a more holistic prevention and care model.
https://www.cdc.gov/poxvirus/Mpox/response/2022/demographics.html
https://www.cdc.gov/poxvirus/Mpox/response/2022/Mpox-trends.html
https://dph.georgia.gov/search?search=Mpox&sm_site_name=dph
https://www.cdc.gov/poxvirus/Mpox/response/2022/us-map.html
https://www.cdc.gov/endhiv/about.html
https://www.cdc.gov/hiv/statistics/overview/index.html
https://www.cdc.gov/poxvirus/Mpox/response/2022/index.html
https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e3.htm