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Incorporating HIV Prevention into the Medical Care of Persons Living with HIV

Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Introduction and Rationale. Ask ∙ Screen ∙ Intervene. Developed by : The National Network of STD/HIV Prevention Training Centers, in conjunction with the AIDS Education Training Centers.

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Incorporating HIV Prevention into the Medical Care of Persons Living with HIV

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  1. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Introduction and Rationale Ask∙Screen∙Intervene Developed by: The National Network of STD/HIV Prevention Training Centers, in conjunction with the AIDS Education Training Centers

  2. Learning Objective:Introduction to AHP and PWP • Describe rationale for implementing consensus recommendations

  3. AHP Strategies Four priority strategies: • Make voluntary HIV testing a routine part of medical care • Expand HIV testing outside medical settings • Prevent new infections by working with persons diagnosed with HIV and their partners • Further decrease perinatal HIV transmission MMWR April 18, 2003/52(15);329-332

  4. Prevention with Positives (PWP):The Recommendations • Developed by CDC, HRSA, NIH, HIVMA, with evidence-based approach • Apply to medical care of all HIV-infected adolescents and adults • Intended for those providing medical care to HIV-positive persons MMWR, July 18, 2003

  5. PwP What are the Recommendations? Medical providers can substantially affect HIV transmission when they • screen for risk behaviors • identify and treat other STDs • communicate prevention messages • discuss sexual and drug-use behavior • positively reinforce changes to safer behavior • refer patients for services (substance abuse treatment) • facilitate partner notification, counseling, and testing MMWR, July 18, 2003

  6. Why PWP? • Most people who are aware of their HIV infection are practicing safer sex • “Every HIV transmission event involves a person already HIV infected” (IOM) • Those living with HIV are fewer in number and easier to define that those at risk • Most HIV+ persons have contact with healthcare system • Better prevention services to HIV+ will improve their health outcomes

  7. Driving Concerns Behind the New Initiative:Are HIV Prevention Efforts Working? • Prevention efforts to date have emphasized working with HIV-negative persons to remain uninfected • CDC estimates • 40,000 new HIV infections occur in the U.S. each year • Essentially no change in this number over the last decade • One quarter of HIV-infected Americans do not know they are infected • Recent increases in STDs suggest increases in unsafe sexual behaviors • STDs increase HIV transmission risk by 2-5 fold

  8. 180 180 160 160 140 140 120 120 Estimated Number of Annual Infections (X 1,000) 100 100 80 80 60 60 40 40 20 20 0 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 Estimated Number of New HIV Infections in US Annually

  9. ~25% Unaware of Infection Accounting for: ~55% of New Infections ~75% Aware of Infection ~45% of New Infections New Infections Each Year: ~40,000 PLW/ HIV/AIDS 850,000-950,000 Awareness of Serostatus Among People with HIV and Estimates of Transmission in US

  10. Proportion on Men Reporting Anal Sex Before and After Knowing HIV-Positive Status Percent Reporting Risk Behavior Colfax et al, AIDS 2002

  11. Why is it Important NOW? Emerging trends among the HIV-infected: • Increases in unsafe sex • Increases in syphilis, gonorrhea • Transmission of drug-resistant virus STDs increase amount of HIV shed at genital mucosa (cervix, urethra, rectum) • Directly increases risk of transmitting HIV • Rietmeijer, Chen, Collis, Novak, Tang, Weinstock, Blackard, Jost, Erbelding

  12. Emerging Trends Among HIV-Infected Men-Who-Have-Sex-With-Men (MSMs)

  13. MSM Prevalence Monitoring Project — Test positivity for gonorrhea and chlamydia among men who have sex with men, by HIV status, STD clinics, US, 2003

  14. Gonococcal Isolate Surveillance ProjectPercent of Neisseria gonorrhoeae isolates with resistance to ciprofloxacin by sexual behavior, 2001–2003

  15. Primary and Secondary Syphilis Cases, by Sex, 1997-2002: Some Large US Cities Males Females New York City Los Angeles 400 400 200 200 0 0 1998 1999 2000 2001 1998 1999 2000 2001 1997 2002 1997 2002 San Francisco Chicago 400 400 200 200 0 0 1998 1999 2000 2001 1998 1999 2000 2001 1997 2002 1997 2002

  16. HIV Status Among Men Who Have Sex With Men Primary & Secondary Syphilis Cases - California,2001–2003 8/2004 Provisional Data - CA DHS STD Control Branch

  17. Why is this Occurring? • Improved HIV therapy, well-being, and survival • “Prevention fatigue” • Increased use of erectile dysfunction drugs, methamphetamine, poppers • Old & new ways to meet partners • Baths, parks • Internet • Anonymous partners Ciesielski 2003, Katz 2002

  18. The STD CofactorMechanisms by Which STDs Increase HIV Spread • Transmission: • Inflammatory conditions increase viral load in secretions • Virus can be cultured from genital ulcers • Susceptibility: • Breaks in epithelial barrier allow viral access • Inflammation increases number and/or receptivity of target cells • Enhancement of viral survival (increased pH and/or lack of H2O2 in vagina may lead to prolonged viral survival)

  19. Urethritis Increases HIV in Semen Median concentrationof HIV-1 RNA in semen among 135 HIV-infected men in Malawi w/ and w/o urethritis Treatment x 104 copies/ml Cohen M et al. Lancet 1997; 349: 1868-1873

  20. Effect of STD on HIV SusceptibilitySummary Estimates (ORs) from Cohort Studies Rottingen et al STD 2001

  21. The Impact of STDs on Sexual Transmission of HIV • Similar behaviors transmit HIV and STDS • Vaginal and anal intercourse • STDs increase susceptibility to and infectiousness of HIV infection • Risk of HIV transmission is 2 to 5 times higher in the presence of other STDs SO… Risk assessment and STD screening is an effective intervention for reducing HIV transmission Wasserheit& Fleming

  22. Prevention with Positives:What Providers Can Do • ASK • Assess for sexual and IDU risk behaviors • SCREEN • Identify and treat STDs • Assess for pregnancy • INTERVENE • Provide prevention messages & behavioral risk-reduction interventions • Refer for Partner Counseling and Referral Services

  23. Additional Information on AHP • www.cdc.gov/hiv/partners/ahp.htm • CDC. Advancing HIV prevention: New strategies for a changing epidemic. MMWR 2003;52:329-332 • www.stdhivtraining.org • www.paetc.edu

  24. Acknowledgments… • HIV Prevention in Care Curriculum Working Group (NNPTC-AETC) • CDC Program Liaisons

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