Mandate for Early HIV Detection

1. Mandate for Early HIV Detection Ann M. Khalsa, MD ,MSEd Director of AIDS Training Texas Oklahoma AIDS Education & Training Center Centro de Salud La Fe HIV/AIDS C.A.R.E. Center Texas Tech University Health Sciences Center El Paso, Texas, USA

2. 2 Continued expansion of HIV pandemic US: steady rate new cases, plateau AIDS & deaths International: increasing cases & rates Transmission prevention Inadequate knowledge of HIV sero-positivity STD resurgence, continued high risk behavior, transmitted drug resistance Reduced STDs, risk & transmission when know HIV+ Availability of effective interventions Rapid testing in routine medical care Effective risk reduction strategies Reasons for Early HIV DetectionOUTLINE

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5. 5 UNAIDS HIV/AIDS Estimates:Annual Increases (Decreases)

6. 6 Continued expansion of HIV pandemic US & international case increases Transmission prevention Inadequate knowledge of HIV sero-positivity STD resurgence, continued high risk behavior, transmitted drug resistance Reduced STDs, risk behaviors & transmission when know HIV+ Availability of effective interventions Rapid testing in routine medical care Effective risk reduction strategies Reasons for Early HIV DetectionOUTLINE

7. 7 Inadequate Knowledgeof HIV Sero-Status

8. 8 Inadequate Knowledgeof HIV Sero-Status 34% of 329 HIV+ children born 1995-96 to mothers NOT tested before birth Lindegren. JAMA 1999;282:531--8. Reasons for no test:- No prenatal care, e.g. substance abuse- Refused: test not emphasized by doc. CDC MMWR 2001:50(RR19):59-86.

9. 9 Knowledge of HIV Status:Erroneous & Inadequate San Francisco cohort, gay/ bisexual men, ages 18-29 yr

10. 10 Resurgent Risk Behaviors & STDs

11. 11 Resurgent STDs in Era of HIV / AIDS

12. 12 Resurgent STDs in Era of HIV / AIDS

13. 13 Continued Sexual Risk BehaviorFollowing HIV Diagnosis

14. 14 Heterosexual Transmission:Increased at Higher VL

15. 15 Heterosexual Transmission:Increased at Higher VL 415 couples in Uganda x 30mo, 55%men+ 90 couples (22%) seroconverted: 12%/yr: M? F = F? M 23%/yr: VL >50,000 vs 0% VL <1500 2.45 x ? risk of transmission  with each 1 log VL ? (p<0.0001)

16. 16 Primary HIV-1 Drug Resistance Among Recently Infected Persons Mutations associated with resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) steadily increased from 0% in 1996-1997 to 12 (13.2%) in 2000-2001 (P = .01). There was 1 mutation associated with protease inhibitor resistance in 1996-1997 (2.5%) and there were 7 (7.7%) in 2000-2001 (P = .25). Genotypic resistance to nucleoside reverse transcriptase inhibitors (NRTIs) initially decreased and then returned to prior levels (P = .007 for test of homogeneity). Genotypic resistance to 2 or more classes of drugs increased from 1 (2.5%) to 12 (13.2%) (P = .004), but only 1 infection (1.2%) in the latter period was resistant to all 3 classes of agents (P = .58). Primary phenotypic resistance decreased for NRTIs from 21% to 6.2% (P = .03) and increased for NNRTIs from 0 to 8 (9.9%) (P = .02). Phenotypic resistance increased for protease inhibitors from 2.6% to 6.2% (P = .32). Median time to virologic suppression (<500 copies/mL) during therapy was 12 weeks for patients with genotypic evidence of resistance compared with 5 weeks for patients with drug-sensitive infections (P = .02). Conclusions: The frequency of primary resistance to NNRTIs is increasing, although resistance to all available classes of antiretroviral therapy remains rare. Genotypic resistance testing in recently infected persons predicts time to viral suppression during therapy.Mutations associated with resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) steadily increased from 0% in 1996-1997 to 12 (13.2%) in 2000-2001 (P = .01). There was 1 mutation associated with protease inhibitor resistance in 1996-1997 (2.5%) and there were 7 (7.7%) in 2000-2001 (P = .25). Genotypic resistance to nucleoside reverse transcriptase inhibitors (NRTIs) initially decreased and then returned to prior levels (P = .007 for test of homogeneity). Genotypic resistance to 2 or more classes of drugs increased from 1 (2.5%) to 12 (13.2%) (P = .004), but only 1 infection (1.2%) in the latter period was resistant to all 3 classes of agents (P = .58). Primary phenotypic resistance decreased for NRTIs from 21% to 6.2% (P = .03) and increased for NNRTIs from 0 to 8 (9.9%) (P = .02). Phenotypic resistance increased for protease inhibitors from 2.6% to 6.2% (P = .32). Median time to virologic suppression (<500 copies/mL) during therapy was 12 weeks for patients with genotypic evidence of resistance compared with 5 weeks for patients with drug-sensitive infections (P = .02). Conclusions: The frequency of primary resistance to NNRTIs is increasing, although resistance to all available classes of antiretroviral therapy remains rare. Genotypic resistance testing in recently infected persons predicts time to viral suppression during therapy.

17. 17 Resistance Prevalence in the US

18. 18 2 Modes of Drug Resistance Acquisition:The NEED for Different Prevention Strategies Primary Transmitted Resistance From source partner w/ acquired resist who: Knew he/she was infected Had seen a health care provider Had been prescribed ARV therapy To a recipient engaging in high risk behavior Secondary Acquired Resistance Following non-suppressive treatment

19. 19 High-Risk Sexual Behavior inARV-Resistant HIV+ Adults

20. 20 SAFE: CDC Serostatus Approach to Fighting the HIV Epidemic Increase # HIV+ persons aware of serostatus Increase use of HIV preventive services Increase high quality HIV care & treatment Increase HIV treatment adherence Increase # HIV+ persons who sustain HIV-STD risk-reduction behavior

21. 21 CDC’s SAFE Initiative:Medical Benefits of HIV Diagnosis OI prophylaxis ?  ? HIV-related morbidity Tx STD’s, substance abuse, mental health ? ? HIV transmission / risk behaviors Antiretroviral treatment ? ? morbidity, mortality, & transmission

22. 22 CDC’s SAFE Initiative:Public Health Benefits of HIV Diagnosis: ? Partner protection after aware of diagnosis ?  ? HIV transmission ? Viral load in blood & sexual secretionsvia antiretroviral treatment  ? ? Reduced HIV transmission

23. 23 Reduced Sexual Risk BehaviorsFollowing Knowledge of HIV Status CDC study, N=142 pts diagnosed previous 6-24mos, predominantly heterosexual black males

24. 24 Reduced High-Risk Sex After Diagnosis – With Recidivism 1995+ prospective HIV- MSM vaccine cohort (n=3200) 2% newly HIV+ (n=72) 59% = high-risk transmitters(unprotected anal sex during 6month seroconversion period):- insertive w/ HIV-neg/unknown- receptive w/ HIV-neg/unknown- insertive w/ HIV-positive - receptive w/ HIV-positive

25. 25 Reduced STDs with Risk-Reduction Counseling Fewer STI’s in risk- reduction counseling intervention vs standard didactic counseling Patients assigned to arm 1 received enhanced counseling. [10] This 4-session intervention, based on the theory of reasoned action and social cognitive theory, [14-16] sought to change key theoretical elements (eg, self-efficacy, attitudes, and perceived norms) underlying condom use. Session 1 lasted 20 minutes and was conducted during the initial clinic visit; the remaining sessions were 60 minutes each. Test results for HIV were given during session 3. Each session built on lessons from the preceding session. The first 3 sessions concluded with a behavioral goal-setting exercise in which the participant arrived at a small behavioral risk-reduction step that could be achieved before the next session. At the final session, a longer-term, risk-reduction plan for each participant was agreed on. Participants assigned to arm 2 received brief counseling, a 2-session intervention modeled after CDC's recommended HIV counseling for patients attending public clinics and HIV test sites. [17,18] Session 1 (20 minutes) was conducted during the initial clinic visit and was identical to the first session of enhanced counseling. Session 2 (20 minutes) included a discussion of the HIV test result as well as additional counseling. The objectives of brief counseling were to assess actual and self-perceived HIV/STD risk, to help the participant recognize barriers to risk reduction, to negotiate an acceptable and achievable risk-reduction plan, and to support patient-initiated behavior change. The first session concluded with a behavioral goal-setting exercise in which the participant arrived at a small risk-reduction step that could be achieved before the second session. At the second session, progress in completing the behavioral step was reviewed, barriers and facilitators to completing the behavioral step were discussed, and a longer-term risk-reduction plan was developed. Patients assigned to arm 1 received enhanced counseling. [10] This 4-session intervention, based on the theory of reasoned action and social cognitive theory, [14-16] sought to change key theoretical elements (eg, self-efficacy, attitudes, and perceived norms) underlying condom use. Session 1 lasted 20 minutes and was conducted during the initial clinic visit; the remaining sessions were 60 minutes each. Test results for HIV were given during session 3. Each session built on lessons from the preceding session. The first 3 sessions concluded with a behavioral goal-setting exercise in which the participant arrived at a small behavioral risk-reduction step that could be achieved before the next session. At the final session, a longer-term, risk-reduction plan for each participant was agreed on. Participants assigned to arm 2 received brief counseling, a 2-session intervention modeled after CDC's recommended HIV counseling for patients attending public clinics and HIV test sites. [17,18] Session 1 (20 minutes) was conducted during the initial clinic visit and was identical to the first session of enhanced counseling. Session 2 (20 minutes) included a discussion of the HIV test result as well as additional counseling. The objectives of brief counseling were to assess actual and self-perceived HIV/STD risk, to help the participant recognize barriers to risk reduction, to negotiate an acceptable and achievable risk-reduction plan, and to support patient-initiated behavior change. The first session concluded with a behavioral goal-setting exercise in which the participant arrived at a small risk-reduction step that could be achieved before the second session. At the second session, progress in completing the behavioral step was reviewed, barriers and facilitators to completing the behavioral step were discussed, and a longer-term risk-reduction plan was developed.

26. 26 Treatment of STDs ?Reduced HIV in Semen

27. 27 ARV Reduction in Plasma VL ?Reduced HIV in Semen

28. 28 ARV in Pregnancy ?Reduced Perinatal Transmission AZT monotherapy: ACTG 076 Wk 14+ 22.6% ? 7.6% Thailand Wk 36+ 19% ? 9% USA L & D+ 27% ? 10% NVP single dose: HIVNET 012 (+BrFd) 1 dose 21% ? 12% AZT + 3TC (IP/PP): PETRA (Afr,+BrFd) L & D+ 15% ? 6% Triple therapy: DITRAME-1.1 (AZT/3TC+sdNVP) ? 5 % USA: w/ AZT & PI std. tx ? 1.2% Current US observed transmission on HAART 0-2%!

29. 29 Reasons for Early HIV DetectionOUTLINE Continued expansion of HIV pandemic US: steady rate new cases, plateau AIDS & deaths International: increasing cases & rates Inadequate transmission prevention Inadequate knowledge of HIV sero-positivity STD resurgence, continued high risk behavior, transmitted drug resistance Reduced STDs, risk & transmission when know HIV+ Availability of effective interventions Rapid testing in routine medical care Effective risk reduction strategies

31. 31 HIV Diagnostic Tests ANTIBODY TESTS ELISA Serum run twice WB Confirmatory Specimens Venous Lab standard Rapid “Ora-Quick” & others Oral “Ora-Sure” (mail) Home “Home Access” VIRAL RNA TESTS PCR or bDNA Earliest diagnosis

32. 32 FDA-Approved Rapid HIV Tests OraQuick is the test being most widely utilized because the Plasma and serum tests require centrifugation, and are therefore not CLIA waived. Also, the OraQuick gives you a time range for returning to the lab area to read the result, which fits into clinic schedules easier (e.g. while seeing another patient or while going back in the room for further risk assessment and pre-test counseling of the patient.) Note the interpretation of results – as written on the slide, including: If the screening OraQuick is positive, a confirmatory blood WB must be ordered. However since WB test are usually performed in labs AFTER their screening EIA is positive – the WB might NOT get run if their EIA is negative. Therefore the WB should be ordered with the instructions to run the WB even if the lab EIA is negative. The slight increased sensitivity of lab bloods test is considered to be offset by the increased acceptance and use of the oral tests.OraQuick is the test being most widely utilized because the Plasma and serum tests require centrifugation, and are therefore not CLIA waived. Also, the OraQuick gives you a time range for returning to the lab area to read the result, which fits into clinic schedules easier (e.g. while seeing another patient or while going back in the room for further risk assessment and pre-test counseling of the patient.) Note the interpretation of results – as written on the slide, including: If the screening OraQuick is positive, a confirmatory blood WB must be ordered. However since WB test are usually performed in labs AFTER their screening EIA is positive – the WB might NOT get run if their EIA is negative. Therefore the WB should be ordered with the instructions to run the WB even if the lab EIA is negative. The slight increased sensitivity of lab bloods test is considered to be offset by the increased acceptance and use of the oral tests.

33. 33 OraQuick ADVANCE® Rapid HIV-1/2 Test Note that this can be done on swiped mucosa, venipuncture specimen or a finger stick. Reading it is as simple as interpreting a urine pregnancy test or a rapid strep test. It costs ~ $15 per test, plus a ~$15 control test every month or so.Note that this can be done on swiped mucosa, venipuncture specimen or a finger stick. Reading it is as simple as interpreting a urine pregnancy test or a rapid strep test. It costs ~ $15 per test, plus a ~$15 control test every month or so.

34. 34 OraQuick ADVANCE® Rapid HIV-1/2 Test – cont’d Note that this can be done on swiped mucosa, venipuncture specimen or a finger stick. Reading it is as simple as interpreting a urine pregnancy test or a rapid strep test. It costs ~ $15 per test, plus a ~$15 control test every month or so.Note that this can be done on swiped mucosa, venipuncture specimen or a finger stick. Reading it is as simple as interpreting a urine pregnancy test or a rapid strep test. It costs ~ $15 per test, plus a ~$15 control test every month or so.

35. This tests antibodies from tissue fluid that exudes into pad over two minutes that the swab is in place between gums and cheek. It takes ~2wks to come back, but is as definitive as a blood test. Also, in “testing vans” – they now usually do an onsite “OraQuick” EIA screen, and if positive do a repeat oral swab for an OraQuick (that they send out).This tests antibodies from tissue fluid that exudes into pad over two minutes that the swab is in place between gums and cheek. It takes ~2wks to come back, but is as definitive as a blood test. Also, in “testing vans” – they now usually do an onsite “OraQuick” EIA screen, and if positive do a repeat oral swab for an OraQuick (that they send out).

36. 36 HIV Testing Indications:3 Categories Risk Factors for HIV Infection Sex, IV drugs, blood, contact with at-risk person (see next section) Manifestations of HIV Infection Acute retroviral syndrome Chronic non-specific symptoms of HIV AIDS conditions Medical Conditions Affected by HIV = commonly thought about ! = NOT commonly thought about – therefore = learning point= commonly thought about ! = NOT commonly thought about – therefore = learning point

37. 37 Acute retroviral syndrome: Fever, adenopathy, pharyngitis, rash, etc. 50-80%, within first 6wks Non-specific, early HIV S/Sx: Lymphadenopathy, onychomycosis, shingles, recurrent vaginitis, hypergamma-globulinema, neutropenia, thrombocytopenia, etc. AIDS opportunistic infections / cancers: PCP, esophagitis, diarrhea, lymphoma, etc. HIV Testing Indications:2. Manifestations of HIV ! = again, NOT COMMONLY recognized – e.g. / CASE EXAMPLES: . Onychomycosis: early 1980’s in San Francisco the public health department used to scan gay bars and parks for guys with funky fingernails . Shingles: yes, we can all get an outbreak from stress – but in a young non-DM person HIV should be considered . Recurrent Vaginitis: R/O HIV is rightly on OTC package inserts – eg Monistat . Hypergammaglobulimea: Audience ?: how do you detect on routine chem panel? Answer: elevated total protein with nl-low albumin . Cytopenias: Late 1990’s patient sent from Catalina island to USC for use of CT scanner (no CT’s on island) to R/O basilar skull fracture – due to periorbital ecchymosis after being kicked in the head by a horse (worked on horse ranch), CT negative but observed to have low WBC and platelets, perceptive doc did risk assessment and testing: HIV+ MSM! = again, NOT COMMONLY recognized – e.g. / CASE EXAMPLES: . Onychomycosis: early 1980’s in San Francisco the public health department used to scan gay bars and parks for guys with funky fingernails . Shingles: yes, we can all get an outbreak from stress – but in a young non-DM person HIV should be considered . Recurrent Vaginitis: R/O HIV is rightly on OTC package inserts – eg Monistat . Hypergammaglobulimea: Audience ?: how do you detect on routine chem panel? Answer: elevated total protein with nl-low albumin . Cytopenias: Late 1990’s patient sent from Catalina island to USC for use of CT scanner (no CT’s on island) to R/O basilar skull fracture – due to periorbital ecchymosis after being kicked in the head by a horse (worked on horse ranch), CT negative but observed to have low WBC and platelets, perceptive doc did risk assessment and testing: HIV+ MSM

38. 38 Low Prevalence Group Members: Risk May be High 57 yr grandmother univ. secretary – w/ acute “flu” Divorced with new 39 y/o boyfriend 65 yr married grandmother – recurrent vag.candida Husband raped at campground 72 yr surgeon’s widow – recurrent thrush, dry cough Died of late-diagnosed PCP (boyfriend) 43 yr father with pregnant wife – single lymph node Prior MSM contacts in bars University secretary, seen at clinic for “flu”, EBV & influenza ruled out, turned out to be acute HIV. This is the “case” profiled in this lecture.Boyfriend didn’t know was HIV+ until she came down with acute HIV. Of course no condoms were used because she was post-menopausal. Presented to primary care doc with recurrent candida vagninits, eventually traced HIV infection back to rape of husband – when he picked up a hitchhiker en route to regional campground for a family holiday. Woman hospitalized for pneumonia. Treated initially for community acquired pneumonia, but quickly worsened and ended up in the ICU. By the time PCP was entertained – she was too ill to recover. Prior manifestations of HIV had all been missed – recurrent candida vaginitis, shingles, thrush. Source of HIV was a non-English speaking boyfriend with whom she had had a long distance relationship over the course of 5+ years – after meeting him on a cruise in the Mediterranean. Husband seen at local LA Free Clinic for a large lumph node in the neck. TB skin test negative, so free-clinic doc suspected AIDS-lymphoma. HIV test positive – referred to County AIDS clinic. Patient’s wife at the time was 6 months pregnant with their second child. He refused treatment for both the (subsequently-confirmed) lymphoma and HIV/AIDS – because didn’t want to be ill with treatment-side effects after baby’s birth (and had severe denial). By the time he accepted treatment 6 months later his lymphoma was marrow-disseminated and he was severely pancytopenic. But he responded to treatment, & is now in complete remission, with CD4 >200 and VL undetectable, and all family members HIV-negative.University secretary, seen at clinic for “flu”, EBV & influenza ruled out, turned out to be acute HIV. This is the “case” profiled in this lecture.Boyfriend didn’t know was HIV+ until she came down with acute HIV. Of course no condoms were used because she was post-menopausal. Presented to primary care doc with recurrent candida vagninits, eventually traced HIV infection back to rape of husband – when he picked up a hitchhiker en route to regional campground for a family holiday. Woman hospitalized for pneumonia. Treated initially for community acquired pneumonia, but quickly worsened and ended up in the ICU. By the time PCP was entertained – she was too ill to recover. Prior manifestations of HIV had all been missed – recurrent candida vaginitis, shingles, thrush. Source of HIV was a non-English speaking boyfriend with whom she had had a long distance relationship over the course of 5+ years – after meeting him on a cruise in the Mediterranean. Husband seen at local LA Free Clinic for a large lumph node in the neck. TB skin test negative, so free-clinic doc suspected AIDS-lymphoma. HIV test positive – referred to County AIDS clinic. Patient’s wife at the time was 6 months pregnant with their second child. He refused treatment for both the (subsequently-confirmed) lymphoma and HIV/AIDS – because didn’t want to be ill with treatment-side effects after baby’s birth (and had severe denial). By the time he accepted treatment 6 months later his lymphoma was marrow-disseminated and he was severely pancytopenic. But he responded to treatment, & is now in complete remission, with CD4 >200 and VL undetectable, and all family members HIV-negative.

39. 39 Pregnancy Pelvic Inflamm.Disease Syphilis Cervical Dysplasia HPV Disease Tuberculosis HBV & HCV Occupational Expos. Perinatal transmission Abscesses Neuro-syphilis No-cryotherapy Eval for Dysplasia Hi rates concurrence &latent activation! ? Morbidity / mortality Work-Comp HIV Testing Indications:3. Medical Need to Know

40. 40 HIV Prevention Measures:“What Works?” Healthcare provider discussions Interpersonal skills Harm reduction Prevention for positives International models

41. 41 Healthcare Provider Discussions Bring up at any and all clinic visits Goals: Risk assessment & rapid testing Risk reduction via skill development Provider Factors Comfort with topic = most important!! “Normalize” subject: e.g. w/ other infections Watch for distractors (e.g. “I’m divorced”) Have referrals & resources ready Counseling for psychosocial issues HIV & STD treatment

42. 42 HIV Risk Factors “Unprotected” sexual contact, since 1978 Any “STD”, HPV/Pap, OCPs… “Recreational” blood exposure IVDU, tattoos, cocaine straws, etc. Receipt of tissue or blood products Risk 1:60,000 / 1985 ? 1:675,000 / 1996 (USA) “PARTNER” with above risks Person from high prevalence group Note “6-month” negative window

43. 43 Sexual Risk Assessment“Have you…?” Ever had sex since 1978 ? Used condoms 100% ? Used oral contraceptives ? Ever been pregnant ? Ever had: A sexually transmitted infection ? An abnormal Pap smear ? Had sex with men, women or both ? Had sex vaginally, orally or rectally ?

44. 44 “Know Thy Partner’s History”Sex with 2 partners AND their 2 partners You 1 ? Your 2 partners 2 ? ? Their 2 partners 6 ? ? ? ? Partners’ partners 14 ? ? ? ? ? ? ? ? ‘‘ ‘‘ 30 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ‘‘ ‘‘ 62 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ‘‘ ‘‘ 126 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

45. 45 “Know Thy Partner’s History” Sex with 2 People ? HIV+ You 1 ? Your 2 partners 2 ? ? Their 2 partners 6 ? ? ? ? Partners’ partners 14 ? ? ? ? ? ? ? ? ‘‘ ‘‘ 30 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ‘‘ ‘‘ 62 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ‘‘ ‘‘ 126 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

46. 46 Interpersonal Prevention Skills LEARN HOW TO ASK PARTNER/S: History of prior sex / drug partners History of prior sexual infections History of prior HIV testing LEARN HOW TO NEGOTIATE: Use of condoms / barriers Safer sex / drug practices

47. 47 Harm Reduction Incremental reduction of harm through accomplishable intermediate changes Versus “all or nothing” Developed in NY area initially in context of substance abuse Subsequently generalized to HIV context “W.H.O. must give a clear message:HARM REDUCTION WORKS.” Jim Kim, WHO, CROI 2005

48. 48 Harm Reduction - Application Assume continued risk behavior Therefore “reduce harm” via “safer” sexual & drug use practices, e.g.: Know HIV sero-status Disclose HIV status Don’t make false assumptions, i.e. “he didn’t tell me – therefore he must be…” Reduce number of partners

49. 49 Prevention For Positives Discuss risk activities at every visit Inquire about specific activities: Having sex? (Using needles?) Disclosing diagnosis? Using protection? Having anonymous sex? Having sex while using drugs? Offer harm reduction: Condoms, counseling, referrals, etc. Suggest safer practices, counter mis-understandings Partner notification &/or testing

50. 50 International Prevention Models“ABC” –and – “CNN” Abstinence Be Faithful Condoms Condoms Negotiation Needle Exchange