HIV/AIDS in INDIAN COUNTRY: Do we have a problem?

1. HIV/AIDS in INDIAN COUNTRY:Do we have a problem? Dee Ann DeRoin, MD, MPH National Native HIV/AIDS Awareness Day March 20, 2008

2. WHY ARE WE HERE? • To discuss the enormous risk for an HIV outbreak in one or more Indian communities • To underscore the new CDC recommendations for routine screening

3. Revised Recommendations for HIV Screening in Health-Care Settings in the U.S. September, 2006

4. CDC Recommendation for HIV Screening Opt-out HIV screening and HIV diagnostic testing should be a part of routine clinical care in all healthcare settings. This information is based on: Centers for Disease Control and Prevention (CDC). (2006, September 22). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Information take from: http://www.cdc.gov/hiv/topics/testing/healthcare September 22, 2006

5. The CDC recommends that HIV screening be a routine part of health care for all: • Individuals in the U.S. between the ages of 13 and 64 • Patients receiving care for tuberculosis (TB) • Patients in care for other sexually transmitted diseases (STDs) • Women who are considering conception and pregnancy • Women who are pregnant • Women in delivery who have undocumented HIV status at the onset of labor • Infants born to mothers with undocumented HIV status.

6. A QUICK HIV REVIEW

7. HIV Transmission • Contact with infected body fluids (blood, semen, vaginal fluid, breast milk) • Unprotected sex • Sharing needles • Mother to fetus

8. Time Line of HIV Infection Positive Ab Test result (6 months) Asymptomatic HIV Infection Symptomatic HIV Infection Acute Infection AIDS DEATH? ? Years 10-15 Years 3-5 Years

9. Typical Course of Untreated HIV Infection 1100 Primary Infection Death 1100 • Possible acute HIV syndrome • Wide dissemination of virus • Seeding of lymphoid organs 1000 1:512 Opportunistic disease 900 1:256 Clinical Latency 800 1:128 700 1:64 CD4 T Cells/mm3 Plasma Viremia Titer 600 1:32 Constitutional symptoms 500 1:16 400 1:8 300 1:4 200 1:2 100 0 0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11 Weeks Years Pantaleo et al, NEJM, 1993

10. Signs of Acute Infection • Fever (can be HIGH) • Lymphadenopathy • Rash (upper body, scattered oval macules) • Ulcers: oral, pharyngeal, esophageal, genital • Thrush Source: http://hivinsite.ucsf.edu

11. Symptoms • Flu-like symptoms • Malaise, fatigue, myalgias, arthralgias • Sore throat, mouth (no rhinorrhea) • GI symptoms: abdominal pain, diarrhea • Meningeal symptoms: head ache, photophobia, stiff neck • Dehydration symptoms Source: http://hivinsite.ucsf.edu

12. Routine Lab Abnormalities • WBC is LOW • Lymphocytopenia • Thrombocytopenia (100K) • Mild transaminitis Source: http://hivinsite.ucsf.edu

13. Diagnosis • Symptoms: 3-6 weeks after exposure • Antibody seroconversion • 1 to 10 weeks after onset of sx • HIV-1 RNA tests (PCR, bDNA) • Positive 1 - 2 weeks before antibody • Risk of false positives - only use if high pre-test probability Source: http://hivinsite.ucsf.edu

14. BASIC TENETS OF DENTAL CARE IN THE HIV/AIDS PATIENT

15. Oral Guidelines • The guidelines for good oral health care are the same for HIV positive people as they are for all dental patients

16. Source: CDC, MMWR, December 19, 2003:52(RR-17).Date: 12/19/2003 http://www.cdc.gov/oralhealth/infectioncontrol/ guidelines/index.htm Guidelines for Infection Control in Dental Health-Care Settings

17. Oral Manifestations of HIV Infection • Oral manifestations may be among the first signs of HIV infection and thus may lead to testing and diagnosis of HIV infection. • Oral conditions may develop as immunosuppression progresses, causing signs and symptoms that require management. Warning!

18. Treatment Planning For The HIV+ Patient Follows The Same Guidelines As For Non-HIV+ • Relieve pain • Restore function • Prevent further disease • Consider esthetic results

19. General Treatment Planning • Modifications of care for the HIV patient are similar to those of any medically compromised person. • As an example, diabetics require special consideration because of their impaired response to bacterial infections as well as delayed healing

20. General Treatment Planning • Strong emphasis must be placed on prevention • Each patient is different and each treatment plan must be prioritized according to that patients health needs. • Deviation from the customary treatment sequence may be indicated

21. Early Stage • Patients with HIV who have a CD4 count above 200 are defined as being in the early stages of the disease. • These patients should be treated the same as HIV negative patients.

22. Late Stage • When CD4 counts fall below 200, patients are considered to have progressed to the later stages of the disease. • Most of these patients are still easily treated in the GP office, but occasionally require antibiotic prophylaxis for invasive procedures.

23. Important! Antibiotic Prophylaxis • Indicated when: • Neutrophils: <500 cells/mm3 • According to AHA guidelines if patient has heart/valvular problems • Need for antibiotic prophylaxis is not based on CD4 count

24. Antibiotic Prophylaxis • Patients with indwelling catheters such as a Hickman catheter may require antibiotic prophylaxis prior to dental care. Medical consultation may be warranted. • Renal dialysis patients with shunts for hemodialysis require antibiotic prophylaxis prior to invasive dental care.

25. Considerations in the Use of Antibiotics • Preferred use of narrow spectrum antibiotics (e.g., Metronidazole) to minimize development of antibiotic resistance • Possibility of presence of antibiotic resistant strains • Culture and antibiotic sensitivity may be indicated • Use of antibiotics may lead to overgrowth of Candida albicans • Antifungal treatment may be indicated in conjunction with systemic antibiotics • Local delivery antibiotics may be useful but have not been evaluated

26. Factors that Predispose to Oral Lesions • CD4+ counts < 200cells/mm3 • Viral load > 3000copies/mm3 • Xerostomia • Poor oral hygiene • Smoking

27. HIV/AIDS IN INDIAN COUNTRY:the Issues • Statistics • Health Care Access • Risk Factors • Testing Barriers • Treatment Availability • Community Attitudes • Resources

28. >462,000 people living with HIV/AIDS in 2004 17% ^ prevalence from 2001 to 2004 Main risk: Sexual contact for both men and women Women: 71% heterosexual; 27% IDU Disproportionate impact: African Americans & Hispanics ‡ Epidemiology of HIV in US Campsmith M, et al. XVI IAC Toronto, Canada, Aug. 13-18, 2006; Abst. MOPE0551

29. HIV 2006 USA • There are currently an estimated 40,000 new HIV infections per year in the United States. • More than half of new HIV infections now occur in persons under 25 years old.

30. NEW U.S. HIV/AIDS DIAGNOSES, 2005 MALES 28,037 = 74% FEMALES 9,893 = 26% TOTAL 38,096 CDC, HIV/AIDS Surveillance Report, vol. 17

31. HIV/AIDS Diagnoses among Adults and Adolescents, by Transmission Category — 33 States, 2001–2004 MSM/IDU 5% Other 1% Other 3% Heterosexual 17% IDU 21% MSM 61% IDU 16% Heterosexual 76% Females (n ≈ 45,000) Males (n ≈ 112,000) MMWR, Nov 18, 2005

32. AI/AN MALE HIV INFECTION SOURCE METHOD% MSM 61 IDU 15 MSM/IDU 11 HETEROSEXUAL 12 OTHER 1

33. AI/AN FEMALE HIV INFECTION SOURCE METHOD% HETEROSEXUAL 68 IDU 29 OTHER 2

34. INFECTION RATES BY RACE 2003 2005 Race/EthnicityRate/100,000 AI/AN 10.4 10.6 AfricanAmerican 75.2 72.8 Hispanic 26.8 28.5 White 7.2 9.0 Asian/PI 4.8 7.6 Native infection rates have been higher than rates for whites since 1995. (CDC, HIV SR, v. 17)

35. US Native Population 2000

36. Native Population in Kansas

37. AIDS in INDIAN COUNTRY as of 2005 • 3,717 cases since early 1980’s • 1,657 deaths • 2,060 living with AIDS • 198 new cases diagnosed in 2005 CDC, HIV/AIDS SR, vol. 17

38. NEW DIAGNOSES, 2000-2003 New cases diagnosed among AI/AN from 2000-2003: Males 505 = 71% Females 210 = 29%

39. Kansas AIDS Cases as of 6/30/2006 Gender Incident AIDS Cases Prevalent AIDS Cases Cumulative AIDS Cases N % N % N % 53 82.8 1,01 7 83.6 2339 87.9 Male Female 11 17.2 200 16.4 322 12.1

40. Age in Years Newly Reported AIDS Cases Prevalent AIDS Cases Cumulative AIDS Cases N % N % N % . . 6 0.5 13 0.5 <13 13 TO 14 . . 1 0.1 3 0.1 15 TO 24 7 6.1 83 7.1 144 5.5 25 TO 34 33 28.7 435 37.2 1030 39.7 35 TO 44 40 34.8 431 36.9 928 35.7 45 TO 54 25 21.7 169 14.5 335 12.9 55 TO 64 6 5.2 37 3.2 104 4.0 65 + 4 3.5 6 0.5 39 1.5 AIDS Cases by Age 6/30/2006

41. Incident AIDS Cases Cumulative AIDS Cases Prevalent AIDS Cases Kansas AIDS Cases through June 30, 2006

42. HEALTH CARE for INDIANS in KS • ITU • Indian Health Service • Tribal • Urban

43. KS INDIAN HEALTH SERVICE(IHS) • Haskell Health Center • IHS White Cloud Health Station • (Ioway Reservation)

44. KANSAS RESERVATIONS

45. FEDERAL FUNDING DISPARITIES

46. Eligibility for IHS Care • Care available at IHS facility: • Enrolled member of federally-recognized tribe • Care beyond local facility: • Live within Contract Health Service (CHS) boundaries • Don’t get sick in June!

47. HIV RISK FACTORS for NATIVES • Lack of knowledge of HIV/STI’s • High STD/STI rates • High rates of substance abuse • High rates of emotional problems • Low SES

48. SUBSTANCE ABUSE • Highest rate of illicit drug use among ethnicities - 12.8% • Second-highest rate of methamphetamine use • Alcohol paradox – highest rate of alcohol mortality = 638% US all races rate highest rate of non-drinkers

49. SEXUALLY TRANSMITTED INFECTIONS • 2nd highest rate of all ethnic groups • Gonorrhea • Chlamydia • 3rd highest rate of syphilis

50. HPV – Human Papillomavirus • Cause of most or all cancer of the cervix – which is one of the preventable cancers • AI/AN cervical cancer rates among highest • Decreasing due to increased Pap smear screening • Gardisil HPV vaccine now available