Protection Against HIV Offered by Other Contraceptive Methods

1. Protection Against HIV Offered by Other Contraceptive Methods • Spermicides • May have activity against gonorrhea, chlamydia • Possible increase in mucosal irritation and genital ulcers, especially with frequent use • Recent UNAIDS clinical trial of sex workers in Africa and Thailand found significantly higher HIV seroconversion rates in nonoxynol-9 users as compared to a placebo vaginal lubricant

2. Protection Against HIV Offered by Other Contraceptive Methods continued • Diaphragm • No significant protection against HIV transmission • Limited STI protection

3. Protection Against HIV Offered by Other Contraceptive Methods continued • IUD • No STI or HIV protection • Increased menstrual flow and duration with nonprogesterone containing IUDs may increase transmission risk and risk of anemia • No increase in cervical HIV shedding four months after insertion. Source: Richardson 1999.

4. Contraception and Prevention of HIV Infection continued • Hormonal methods: oral contraceptive pills, DMPA, Norplant implants • No significant STI or HIV protection • May increase genital tract HIV shedding • Voluntary sterilization • No STI or HIV protection • Decreased risk of PID

5. STIs — Prevention and Treatment STIs, both ulcerative and nonulcerative, facilitate HIV transmission 2–5 fold • Condoms • Sexual behavior change • Recognition of risk factors and early symptoms • Syndromic management • Genital ulcer disease • Urethral discharge in men • Vaginal discharge – limitations

6. STIs – Prevention and Treatment continued • Antenatal screening for syphilis • Linkage to programs treating symptomatic men • Target high-risk individuals • Sex workers and clients • Drug users • Military personnel • Truck drivers

7. Rates of STIs Among Pregnant Women in Dakar, Senegal, 1991–1996 Source: UNAIDS 2001.

8. Comparison of Increase in Condom Use with Decline in Reported Male STIs on a National Scale, Thailand, 1989–1994 Source: UNAIDS 2001.

9. Ways to Reduce Risk of Transmission • Injection drug use • Offer drug treatment • Avoid sharing or reusing needles or other injection equipment or supplies • Offer needle exchange programs OR • Clean injection equipment with high-level disinfection of needles and syringes by soaking in 0.5% bleach or boiling for 10 minutes • Use boiled water to prepare drugs or equipment • Clean injection site before injection • Safely dispose of syringes after use

10. Ways to Reduce Risk of Transmission • Traditional Practices • Avoid female circumcision – may increase risk of trauma or bleeding with intercourse • Do not share sharp instruments used in ritual cutting, tattooing practices OR • High-level disinfect instruments after each use

11. MTCT Transmission with Short Course Oral ARV Regimens

12. Preventing MTCT in Low-Resource Settings — Breastfeeding • HIV-negative women or women with unknown HIV status • Breastfeed exclusively for 6 months • Reinforce use of condoms during breastfeeding • HIV-positive women • Avoid if safe and affordable alternatives available • Teach proper attachment of newborn to nipples and frequent breast emptying • Seek prompt treatment of mastitis or breast abscess and oral thrush in newborns • Breastfeed exclusively for up to 6 months Photo by: Hugh Rigby, Kenya, 1982

13. Prevention — Transfusion-Related • Prevent or treat causes of anemia and blood loss • Malnutrition • Malaria • Parasitic infestation • Pregnancy (repeated pregnancies at short intervals, postpartum hemorrhage) • Minimize unnecessary transfusions: Use blood substitutes (crystalloid /colloid) for volume replacement when possible

14. Prevention — Transfusion-Related continued • Select donors carefully: Family replacement and paid or professional donors higher risk • Screen blood supply

15. Barriers to Prevention for Women • Stigma of HIV • Women often unaware of partner’s infection status or level of risk • Women may be unable to negotiate safer sex practices • Sexual coercion • Domestic violence • Economic vulnerability

16. Prevention Lessons Learned • Focusing on high-risk groups is not enough • Risk behavior and vulnerability should be emphasized • Knowledge and awareness are important but not sufficient • Life skills training (sexual negotiation) • Condom promotion • Long-term change in social norms

17. Prevention Lessons Learned continued • Socioeconomic interventions to reduce vulnerability are needed • Education of girls • Protection of human rights • Reduction of stigma

18. Antiretroviral Therapy and Prevention • ARV for HIV-infected persons: • Reduces risk of sexual transmission • Reduces incidence of TB • Promotes HIV testing • Barriers • Complex regimens • Resistance issues • Side effects and toxicity • Cost

19. HIV Prevention — Future Research • Microbicides • Postexposure prophylaxis • Vaccines

20. References • Anderson J. HIV and reproduction. In Anderson J (ed): A Guide to the Clinical Care of Women with HIV. HRSA/DHHS, 2001. • Armed Forces Research Institute of Medical Sciences. Thailand. • Chamratrithirong et al. Review of the 100% Condom Programme, Mahidol University. 2001. • Compendium of HIV prevention interventions with evidence of effectiveness. Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia. November 1999. • Consultation on STD interventions for preventing HIV: What is the evidence?UNAIDS. May 2000. • Female condom-guide for planning and programming. UNAIDS. August 2000.

21. References continued • HIV prevention needs and successes: a tale of three countries. UNAIDS. May 2001. • HIV prevention strategic plan through 2005. Centers for Disease Control and Prevention. January 2001. Institute of Medicine. No time to lose: getting more from HIV prevention. September, 2000 • Male condom technical update. UNAIDS. September 2000. National STD/AIDS Control Programmes. Senegal and Uganda. • Richardson BA, Morrison CS, Sekadde-Kigondu C, et al. Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS 13:2091-7, 1999. • Royce RA, Sena A, Cates W Jr, and Cohen MS. Sexual transmission of HIV. N Engl J Med 336:1072-8, 1997. • Sex and youth: Contextual factors affecting risk for HIV/AIDS. UNAIDS. May 1999.  

22. References continued • Sittitrai W, Phanuphak P, Barry J, et al. A survey of Thai sexual behaviour and risk of HIV infection. Int J STD AIDS (England), Sep-Oct 1994, 5(5) p377-8. • Sweat M, Gregorich S, Sangiwa G, et al. Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. Lancet 2000;356:113-121. • Thongthai et al. Media Effectiveness Survey. Mahidol University. 2001 • UNICEF, DHS surveys, 1994-1999. • The voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. Lancet 2000;356:103-112. • Wang C and Celum C. Prevention of HIV. In Anderson JR (ed): A Guide to the Clinical Care of Women with HIV. DHHS, HRSA, HAB. Washington, D.C. 2001.