Issues in Secondary Prevention Secondary HIV Prevention

1. Issues in Secondary PreventionSecondary HIV Prevention 2014 HHS Health GAME JAM

2. Issues in Secondary Prevention • Linkage to care • Retention in care • Medication adherence • Viral Suppression/Viral Load • Role of HIV Stigma

3. Number of PeopleLiving with HIV in the U.S.is Growing over Time

4. What is Secondary HIV Prevention? • Promoting health among people living with HIV • Accessing medical care • Taking HIV medications when needed • Maintaining undetectable viral load • Reducing behaviors that put others at risk of HIV • Addressing HIV stigma • Benefits • To individual health • To the public health

5. “HIV Treatment is Prevention”:the HPTN 052 Study

6. HIV Treatment: Multiple Steps

7. People are Lost at Each Step of HIV Treatment CDC MMWR, December 2, 2011; 60(47); 1618-1623 See also: Gardner, McLees, Steiner, del Rio, & Burman. CID 2011

8. More simply put…

9. In other words… http://aids.gov/federal-resources/policies/care-continuum/

10. Age and Racial Disparities in HIVTreatment Engagement and Outcomes • HIV diagnosis + viral suppression sig. lower in younger groups vs. older group • HIV diagnosis sig. lower in Black and Latino groups than whites • All steps lower in Black and Latino groups than whites Hall 2013 JAMA Int Med

11. Linkage to Care

12. Why don’t people get linked to care? • Denial about their HIV status • Stigma associated with being HIV+ • Not wanting to disclose their HIV status to anyone, including health care professionals • Lack of medical care insurance coverage

13. What can be done to improve linkage to care? • Get patients into HIV clinic ASAP • Make a quick connection between diagnosed person and linkage worker • Having HIV testing and medical care/ linkage worker at the same location • Assistance with making appointments • Strengths-based case management

14. Retention in Care

15. Retention in Care • What is Retention in Care? • Staying in care—Because there is no cure for HIV at this time, treatment is a lifelong process. To stay healthy, you need to receive regular HIV medical care. http://aids.gov/federal-resources/policies/care-continuum/

16. Why are people not retained in care? • Perceived stigma with being seen at an HIV clinic • Other competing life events • Lack of trust in health care professionals • Mental health disorders • Problems with alcohol or other drugs http://www.cdc.gov/hiv/prevention/programs/pwp/linkage.html

17. Problems with retention Currently, about 60% of persons with HIV have been tested and have had at least one HIV care visit. However, only about 50% of persons diagnosed with HIV receive regular HIV care (by attending regular medical appointments). http://www.cdc.gov/hiv/prevention/programs/pwp/linkage.html

18. Problems with retention • African Americans are the least likely to be in ongoing care or to have their virus under control. • Younger Americans are least likely to be retained in care or have their virus in check. http://aids.gov/federal-resources/policies/care-continuum/

19. What can be done to address retention problems? • Educate persons at the time of their HIV diagnosis about the benefits of HIV medical care for improving personal health and preventing HIV transmission. • Establish the infrastructure and services to assist persons with HIV to • start HIV medical care shortly after a positive HIV test result, • support long-term retention in HIV medical care, and • re-engage into HIV medical care persons if they have dropped out of care. • Offer services that promote linkage to and retention in care through collaborations among HIV testing providers, community-based HIV prevention providers, HIV care providers, case managers, and health departments. http://www.cdc.gov/hiv/prevention/programs/pwp/linkage.html

20. Antiretroviral Medication Adherenceand Viral Suppression

21. Importance of HIV Medication Adherence • People who take prescribed doses of HIV medicines (antiretrovirals) regularly can suppress their HIV viral load to levels that are undetectable by routine tests • Viral suppression translates into: • Fewer HIV-related illnesses • Reduced mortality (death) • Reduced HIV transmission

22. Why are people not adherent to HIV medications? • Forgetfulness • Stigma associated with taking HIV medications • They haven't told their family or partner that they are HIV+ and therefore don’t want to have their HIV medications at their home • Side effects from the HIV medications • Mental health and substance use problems

23. How can we help individuals living with HIV be more adherent? • Encourage them to use reminders (alarms, pill boxes, etc) to take their medications • Increase social support • Address medication side effects • Health care providers can provide a non-judgmental environment • Screen for mental health and substance use problems and provide care for identified issues • Ensure individuals have stable housing

24. Antiretroviral Therapy (ART)

25. Taking antiretroviral therapy (ART), also known as your HIV medications, is like building a brick wall. You build your brick wall by taking your ART every day. ART Wall You could call it your ART Wall!

26. The lab test that measures your CD4 cells is called your CD4 CELL COUNT. One goal of ART is to keep your CD4 Count high so these cells can protect you. CD4+ T cells are white blood cells that make your immune system work. You have many, many CD4 cells. They help keep you strong and healthy. CD4 + T cell CD4 cells

27. The lab test that measures the amount of virus in your blood is called your VIRAL LOAD. Another goal of ART is to keep your Viral Load as low as possible or undetectable. HIV is a virus that kills your CD4 cells and weakens your immune system. HIV uses your CD4 cells to make more HIV – and kills your CD4 cells in the process. HIV HIV

28. Your ART Wall keeps your CD4 Cell Count higher and your Viral Load lower and that is good! A higher CD4 Cell Count is good. A lower Viral Load is good. An undetectable Viral Load is BEST.

29. When your ART Wall is strong, it can help keep HIV away from your CD4 cells and reduce the amount of HIV in your body. CD4 cells ART Wall HIV

30. REMEMBER: You build your brick wall by taking your HIV medications every day. Try to take your ART at the same time every day: it will be easier to remember to take your meds. Ask your provider what to do if you miss a dose.

31. When you don’t take your HIV medications every day, your ART wall gets weak. ART Wall

32. When your ART Wall is weak, HIV can get through the Wall . . . kill your CD4 cells, and make the Wall weaker.

33. When HIV kills your CD4 cells, your labs CHANGE: Your CD4 cell count goes down and that is not good. Your Viral Load goes up and that is not good.

34. When HIV gets through your ART wall, it may become resistant. Resistance means your medications don’t work as well, so more CD4 cells are killed. ART-Resistant HIV

35. REMEMBER A higher CD4 Cell Count is good. A lower Viral Load is good. An undetectable Viral Load is BEST.

36. Taking your HIV medications every day will protect your CD4 cells, keep you healthy, and prevent resistance. ART Wall

37. Slide Set developed by Lucy Bradley-Springer, PhD, RN, ACRN, FAAN Mountain Plains AIDS Education and Training Center University of Colorado Denver, Anschutz Medical Campus, Aurora CO Contributors Gary Marks, PhD Centers for Disease Control and Prevention, Atlanta GA Christine O’Daniels, BS, RN Centers for Disease Control and Prevention Carter Consulting, Inc., Atlanta GA Marla A. Corwin, LCSW, CACIII Mountain Plains AIDS Education and Training Center University of Colorado Denver, Anschutz Medical Campus, Aurora CO January 2014 The Wall concept of this slide set was based on an NIMH-funded study: Finocchario-Kessler, S., Catley, D., Thomson, D., Bradley-Ewing, A., Berkley-Patton, J., & Goggin, K. (2012). Patient communication tools to enhance ART adherence in low and high resource settings. Patient Education and Counseling, 89, 163-170. doi:10.1016/j.pec.2012.03.020

38. Stigma and HIV Donna Hubbard McCree, PhD, MPH, RPh Associate Director for Health Equity Division of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

39. Disclaimer • "The information presented in this portion of the presentation are the results of a scientific literature review and do not necessarily represent the views of the Centers for Disease Control and Prevention”

40. What is Stigma? Definition – type of “spoiled identity” that occurs when a person or group possesses an attribute that is viewed by others as an undesirable difference. Outcome: Social sanctions against those who possess the attribute (Goffman, 1963

41. What is Stigma? Two forms • External: Anticipation of negative treatment by others, usually a dominant group • Internal: Self-directed internalization of negative societal attitudes held by others Stuber, Meyer , Link B, 2008

42. What is HIV-related Stigma? Definition – socially shared attitudes, beliefs or actions that promote and perpetuate the devalue status of people living with or affected by HIV. (Herk, Capitanio, Widaman, 2002; Steward, Herek, Ramakrishna, Bharat, Chandy, Wrubel, Ekstrand, 2008

43. What is HIV-related Stigma? Social Process of Exclusion Multi-faceted Construct Manifested in Two Ways • External negative attitudes or acts of discrimination against people living with HIV and individuals or groups with whom they are associated • Internal negative feeling , beliefs or actions experienced by people living with HIV Harper, Lemos, Hosek, et al, 2014 Herk, Capitanio, Widaman, 2002 Steward, Herek, Ramakrishna, Bharat, Chandy, Wrubel, Ekstrand, 2008

44. What is HIV-related Stigma? Evidence of a decline in the United States since the 1980s Remains key factor in HIV identification, prevention and treatment Herk, Capitanio, Widaman, 2002 Steward, Herek, Ramakrishna, Bharat, Chandy, Wrubel, Ekstrand, 2008

45. How Stigma May AffectSecondary HIV Prevention Efforts ↓Condom Use ↓Disclosure of Status ↓Long-term adjustment and coping with HIV infection ↑Psychological Stress ↑Sexual and Substance Use Risk Behaviors ↓Adherence to ART and service utilization ↓Engagement in HIV Care Gerbert, Maguire, Bleecker, et al, 1991 Herek, 1990 Herek, Glunt, 1988 Steward, Herek, Ramakrishna, et al, 2008 Lee Kochman, Sikkema, 2002