HIV Prevention: Update 2005

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HIV Prevention Update 2005

• Barbara Weis, MD, MPH TM
• Julie Bender, LCSW-C
• Robbin Alexander, HIV Outreach Worker
• Sinai Hospital of Baltimore
• November 1st, 2005

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HIV Prevention Update 2005

• HIV prevalence and deaths will continue to
  increase without effective interventions.
• Some progress has been made in prevention, but
  much more work is needed.
• What can be done by primary care and ED providers?

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Adults and children estimated to be living with
HIV as of end 2004
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Estimated number of children (lt15 years) newly
infected with HIV during 2004
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About 14 000 new HIV infections a day in 2004

• More than 95 are in low and middle income
  countries
• Almost 2000 are in children under 15 years of age
• About 12 000 are in persons aged 15 to 49 years,
  of whom
• almost 50 are women
• about 50 are 1524 year olds

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Global AIDS Funding

• By 2007, 20 billion will be needed.
• ART to 6 million.
• Support for 22 million orphans.
• HIV counseling and testing for 100 million
  adults.
• School-based AIDS education for 900 million
  students.
• Peer counseling for 60 million young people not
  in school.

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Impact of HIV in Africa

• 8 drop in GDP by 2010 20 drop by 2020.
• gt50 of all illnesses among workers were
  AIDS-related.
• 7 million farm workers have died from AIDS.
• 85 of teacher deaths are from AIDS.
• Life expectancy of sexually active Ugandans has
  fallen from 64 to 42 years.

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The Next Wave of HIV/AIDS Nigeria, Ethiopia,
Russia, India and China

• NIC Report
• ICA2002-04D
• Sept. 2002
• We project China will have 10 to 15 million
  HIV/AIDS cases, and India is likely to have 20 to
  25 million by 2010the highest estimate for any
  country.
  
  
  
  
  
  (2004 UNAID Estimate 4-5 million)

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Baltimore Incident HIV and AIDS Deaths among
HIV and AIDS
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Baltimore Incident AIDS Cases by Race/Ethnicity
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Baltimore Incident AIDS Cases by Gender
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HIV/AIDS in Baltimore City Adjusted

• Zip Pop.-2000 HIV Incidence Prevalence
  HIV/AIDS
• 
  7/1/03-6/30/04 on 6/30/04 pop
• 21208 25,513 1 0.004 7 .03
• 21211 13,536 11 .08 134 0.99
• 21215 53,750 76 0.14 1324 2.46
• 21216 29,356 49 0.17 802 2.7
• 21217 33,725 125 0.37 1662 4.9

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HIV Prevention Based on the Mechanisms of
Transmission

• Biological
• Vaccination.
• Treatment of STDs.
• Circumcision.
• Topical microbicides.
• Treatment with ARVs, Prophylaxis.
• Behavioral
• Voluntary counseling and testing.
• Education and behavioral modification.
• Drug Abuse Treatment, clean syringes.
• Condoms not
  proven effective.

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Hope for a Vaccine

• Monkeys have shown complete or partial protection
  after vaccination.
• Successful vaccines have been developed against
  other retroviruses.
• Almost all humans develop an immune response to
  HIV.
• Some exposed people remain uninfected despite
  exposure or develop protective immune responses
  which contain the virus for long periods.

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HIV Vaccine Biology

• Natural infection results in an immune response
  which doesnt clear the virus.
• Genetically diverse HIV-1 and HIV-2.
• Different clades, or subgroups, are in different
  geographic regions of the world.
• Rapid mutation.
• HIV vaccine must produce mucosal (STD) and
  systemic immunity(blood).
• Currently, more than 30 candidate are being
  tested in 19 countries on six continents.

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HIV Vaccine Challenges

• Pipeline of vaccines is narrowly focused on
  cell-mediated hypothesis.
• Vaccines are difficult to manufacture.
• Results from cell-mediated hypothesis not due
  till 2007. If this fails, the pipeline now in
  trials will be irrelevant.
• No global consensus about which are most
  deserving of large-scale trials.
• May need to settle for improved clinical control
  of disease, not complete prevention.

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HIV Vaccine Ethical Challenges

• Rich countries have the expertise and resources,
  but do not have sufficient numbers of patients
  for clinical trials.
• Poor countries have patients but poor
  infrastructure and inadequate resources.
• History of abuse of vulnerable people in clinical
  trials.
• May require a prime/boost method to stimulate CTL
  and antibody response.

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HIV Vaccine Ethical Challenges

• The first vaccine may be no more than forty or
  fifty per cent effective.
• Will vaccination increase high-risk behavior?
• The second vaccine will not be able to be tested
  against placebo, but against the first vaccine,
  causing logistical nightmares.
• The rate of childhood vaccination in Uganda
  declined from 47 in 1995 to 35 in 2002.
• The cost of the vaccine may be 1000.

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HIV Vaccine Ethical Challenges

• Should every infected participant receive the
  best care available Western or African?
• Will subjects benefit from the research?
• If all vaccine recipients become HIV, what about
  future screening methods? Discrimination?
• Political instability?

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Prevention Perinatal HIV Gold Standard

• Universal screening of pregnant women.
• Prenatal, peri-and postnatal antiretroviral
  therapy.
• Rapid testing in the delivery room of patients
  whose HIV status is unknown.
• Appropriate elective caesarean section.
• Formula for the newborn.

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Enhanced Perinatal Surveillance Baltimore City

• 10 diagnosed during labor 25 no risk factor.
• 80 received ART during pregnancy, 67 during
  labor.
• 55 had positive drug screens during pregnancy.
• 91 had at least one prenatal care visit, only
  17 began PNC during 1st trimester.
• HIV neg infants
• Mothers more likely to start PNC in 1st trimester
  (58vs 17).
• 100 of infants received 6 weeks ART.

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Prevention Perinatal HIV2004

• N America W Eur
• lt100 new cases
• lt2 transmission if prenatal care and
  antiretroviral therapy
• Formula feeding
• lt100 deaths from AIDS under age 15 in 2004

• Sub-Saharan Africa
• 560,000 new cases
• 25-40 transmission with no treatment
• Breastfeeding 14-40 additional risk
• 59 HIV-infected infants die by 18 months

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Perinatal Prevention Resource Poor

• Thailand Not breastfeeding 18 months.
• 1.9 with ZDV at 28 weeks plus single dose
  Nevirapine (NVP), 2.8 at with ZDV 3TC .
• Ivory Coast,Africa breastfeeding 24 mths.
• 22.5 with short-course ZDV vs. 30 placebo,
  15.7 at 18mths. forNVP.
• Increased transmission genital ulcer disease,
  chorioamnionitis, mastitis and malnutrition.
• Antiseptic washes may help since 2/3 of
  transmission after 36 weeks.

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Mother to Child Transmission Breastfeeding

• Breastfeeding adds 14-40 additional risk.
• Breastfeeding accounts for 1/3 of HIV infections
  in children.
• Exclusive breastfeeding is better than mixed
  feeding.
• In Kenya, formula feeding decreased postnatal
  transmission by 40, but still mortality 24 BF
  vs. 20 formula.
• May require ART prophylaxis.

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Barriers Perinatal HIV Prevention

• Antiretrovirals have significant side-effects
  anemia, neutropenia, pancreatitis and neuropathy,
  lactic acidosis.
• Lack of prenatal care.
• Reluctance to be tested.
• Women may develop resistance, especially to
  Nevirapine.
• Lack of money for antiretrovirals.
• Prevention programs reach only 20 of targeted
  population..

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Behavioral prevention CDC New Strategies for a
Changing Epidemic

• Four priorities
• Make voluntary HIV testing a routine part of
  medical care
• Implement new models for diagnosing HIV
  infections 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
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Social Context, Sexual Networks and Transmission

• Concurrent partnerships increase transmission.
• 53 in black men vs. 21 in black women vs. 11
  white women.
• Shortage of men causes low marriage rates and
  higher divorce rates, decreasing monogamous
  relationships. Affects power balance.
• US has one of the highest incarceration rates in
  the world. HIV in inmates is 8-10 times higher.

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Awareness of Serostatus among Persons with HIV,
United States
HIV infected 850,000-950,000 Unaware
of HIV infection 180,000 - 280,000
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HIV Testing in the Emergency Room The Need

• High risk populations use the ED as their only
  source of health care.
• During 1994-1999, AIDS was diagnosed in 41 of
  persons within one year of their first positive
  test. High risk populations use the ED as their
  only source of health care.
• Knowledge of status changes behavior 78-96 used
  a condom with a known Neg. partner, 52-86 with a
  partner of unknown status.

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HIV Testing in the Emergency Room

• Less than 3 of Eds routinely test for HIV.
• Recognition of acute HIV in a Universtiy ER,
  0.8 of Monospots positive for acute HIV.
• High acceptability of testing in the ED (50).
• Decline testing higher rates HIV.
• Early awareness of HIV status is the first step
  in obtaining medical care.

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HIV Testing in the Emergency Room

• Lack of time, privacy, and follow-up, language
  and cultural barriers need to be overcome.
• May need to de-couple HIV tests from extensive
  pre-test prevention counseling.
• Combined antibody and RNA testing of pooled
  specimens may be helpful.
• Targeted screening (IDU, STDs, African American)
  may miss 25 of new infections.
• HIV prevalence of 1 CDC recommends testing all
  patients aged 18 to 54 years.

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Physicians in Practice More needs to be done

• In a 2002 survey of 4226 physicians,
• 24 routinely screened men,
• 30 routinely screened women for HIV.
• Only 80 of OB/GYNs routinely screened all
  pregnant women.
• Only 20-30 verified that partners had been
  referred for testing.

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Advancing HIV Prevention The Four Strategies

• Four priorities
• Make voluntary HIV testing a routine part of
  medical care
• Implement new models for diagnosing HIV
  infections outside medical settings
• Prevent new infections by working with persons
  diagnosed with HIV and their partners
• Further decrease perinatal HIV transmission

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Outreach Testing Sites

• Sex offender groups
• Johns programs
• Half-way houses
• Health fairs
• Strip club workers
• African-born groups
• Drug court support groups

• Chemical Dependency Programs
• Homeless shelters
• Sex worker support program
• Drop-in center for gay youth
• Teen clinic
• Gay bars

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Four FDA-approved Rapid HIV Tests
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Confirmatory Testing

• Confirmatory test essential (not just EIA!)
• For Western blot
• Venipuncture for whole blood
• Oral fluid specimen
• Follow-up testing of persons with negative or
  indeterminate Western blot results after 4 weeks

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Advancing HIV Prevention The Four Strategies

• Four priorities
• Make voluntary HIV testing a routine part of
  medical care
• Implement new models for diagnosing HIV
  infections outside medical settings
• Prevent new infections by working with persons
  diagnosed with HIV and their partners
• Further decrease perinatal HIV transmission

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Prevention Persons Living with HIV

• Outreach for preventive care services.
• Screening for return to high-risk behavior.
• Ongoing prevention messages.
• Referral for treatment substance abuse,
  depression.
• Facilitating partner notification, counselling
  and testing.
• Identifying and treating STDs.

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HIV Prevention Update 2005

• HIV Prevalence and deaths will continue to
  increase without effective interventions.
• Some progress has been made in prevention, but
  much more work is needed.
• More can be done by primary care and ED
  providers.

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R
RESTRICTED Under 17 requires accompanying parent
or adult guardian. For strong language,drug use
and sexuality.
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Do You Know What Your Child Knows?

• Goal by 2010 90 of schools will provide
  education about unintended pregnancy, HIV/AIDS,
  and STDs(baseline 65).
• The percentage dropped to 62 in 2000.
• Current administration's focus is on
  abstinence-only prevention and the small risk
  that a condom may not prevent infection.
• Montgomery County updated health ed curriculum
  homosexuality and condom demonstrations.

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Case Report

• AJ is a 20 year old African American male who has
  been followed at Greenspring Pediatrics since
  birth. He presented two months ago when he was
  informed by the Red Cross after a blood donation
  that he was HIV.
• He has had yearly check-ups since birth. In all
  of the previous check-ups, he had denied any
  sexual activity.
• He continued to deny all sexual activity until a
  social work consult was obtained. He disclosed
  that he had had sex with men.

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Adolescent Risk Behavior

• The notion of risk groups is not useful among
  adolescents.
• Most adolescents engage in some type of risk
  taking behaviors experimentation with tobacco,
  drugs and sex is common.
• The most commonly abused drug among adolescents
  is alcohol.

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CDC Youth Risk Behavior Surveillance High School
Students 1999

• Sexual and Contraceptive Behaviors
• Sexual Intercourse
• 50 had sexual intercourse during their lifetime.
• 36 had sexual intercourse in the previous 3
  months.
• 16 had 4 or more lifetime sexual partners.
• 8 had first sexual intercourse at age lt 13
  years.
• Condom Use
• 58 reported condom use during last sexual
  intercourse.
• Consistent condom use not examined.

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CDC Youth Risk Behavior Surveillance High School
Students 1999

• Alcohol and Other Drug Use
• Alcohol
• Lifetime use- 81 at least one drink
• Current use- 50 one drink in the previous 30
  days
• Marijuana
• Lifetime use- 47 used marijuana
• Current use- 27 used marijuana previous 30 days
  

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Adolescent Risk Behavior

• Sexual behavior is often not the same as sexual
  identity.
• Female adolescents often use anal intercourse to
  prevent pregnancy and maintain cultural standards
  of virginity, unaware they are engaging in the
  highest risk sexual behavior for HIV transmission.

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Components of Effective HIV Education

• Open-ended questions and non-medical language.
• Repetition and reiteration.
• Non-judgmental approach to sexual or drug related
  topics.
• Interactive exchange of information.
• Condoms, condoms, condoms.

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Condom Education

• Demonstration with a condom on the arm, a
  banana..etc. (have condoms to give out.).
• Detailed explanation of when to use a condom
  (before any sexual contact.).
• Discuss barriers to condom use.
• Conversation needs to happen at every visit.

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Does Prevention Education work?

• In 1998, CDC trial enrolled 6,000 heterosexual
  men and women attending STD clinics in Baltimore,
  Denver, Long Beach, Newark and San Francisco.
• 
  
• When counsellors encourage discuss
  prevention strategies rather than simply provide
  a lecture on HIV prevention, it significantly
  reduces their risk of STDs.

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Does Prevention Education work?

• When counsellors talked with, rather than to, men
  and women at risk, 20 fewer men and women and
  40 fewer adolescents developed new STDs the next
  year.
• The encouragement approach was as effective in
  two brief 20- minute encounters as in a more
  extensive 4-session program.

• HIV/AIDS Prevention, December1998.

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HIV Outreach Strategies

• Effective Outreach Strategies include
• Giving the facts
• Being honest
• Gaining trust
• Being non-judgmental
• Listening

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Barriers to Effective Community Outreach

• Stigma about HIV and getting tested.
• Lack of Medical insurance.
• Fear of being judged.
• Little or no knowledge of HIV/AIDS.
• Little knowledge of community resources.

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Impact of HIV Outreach in the Community

• It supports and encourages more people to get
  tested for HIV.
• Encourages and supports change in sexual and drug
  using behaviors.
• Educates people about HIV and its impact.
• Helps young people make better choices.

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Outreach in the Community

• HIV outreach and prevention education should be
  done in
• Schools
• Community Centers
• Recreational Centers
• Churches
• Community Clinics
• Health Fairs
• Any appropriate groups