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Care of Women with HIV Living in Limited-Resource Settings Prevention

Care of Women with HIV Living in Limited-Resource Settings Prevention. Jean R. Anderson, MD Director Johns Hopkins HIV Women’s Health Program. Resources. A Guide to the Clinical Care of Women With HIV: 2001 First Edition To request the guide, send e-mail to ask@hrsa.gov

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Care of Women with HIV Living in Limited-Resource Settings Prevention

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  1. Care of Women with HIV Living in Limited-Resource SettingsPrevention Jean R. Anderson, MDDirector Johns Hopkins HIV Women’s Health Program

  2. Resources • A Guide to the Clinical Care of Women With HIV: 2001 First Edition • To request the guide, send e-mail to ask@hrsa.gov • Care of Women With HIV Living in Limited-Resource Settings tutorial series • For more information about the HIV tutorial series, send e-mail to hiv-aids@jhpiego.net.

  3. Learning Objectives • Why prevention is important • Progress made in HIV prevention • Modes of HIV transmission • Most effective interventions for reducing transmission

  4. Performance Objectives • Explain why prevention is important • Demonstrate progress made in HIV prevention • Discuss the modes of HIV transmission • Describe the most effective interventions for reducing transmission

  5. Risk Perception: Percentage of Sexually Active Women (15–19) Who Think They Are not at Risk of Getting AIDS Guatemala 87% Brazil 52% Niger 87% Chad 60% Mali 46% Togo 45% Haiti 63% Kenya 36% Uganda 21% Zambia 52% Zimbabwe 50% 0 20 40 60 80 100 Percentage Source: UNICEF 1999

  6. Risk Perception: Percentage of Sexually Active Women (15–19) Who Think They Are not at Risk of Getting AIDS 1% Guatemala 87% 1% Brazil 52% 1% Niger 87% 2% Chad 60% HIV prevalence rate in women attending antenatal care clinics in major urban areas (at time of survey) 3% Mali 46% 7% Togo 45% 10% Haiti 63% 16% Kenya 36% 19% Uganda 21% 27% Zambia 52% 30% Zimbabwe 50% 0 20 40 60 80 100 Percentage Source: UNICEF 1999.

  7. Trends in HIV Prevalence in Selected Populations Kampala, Uganda, < 20 year old antenatal clients1 Thailand, 21 year old military conscripts2 25 Dakar, Senegal, all ages antenatal clients1 20 HIV prevalence (%) 15 10 5 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Source: 1National STD/AIDS Control Programmes; 2Armed Forces Research Institute of Medical Sciences

  8. Percentage Sexually Experienced by Current Age (15–24 years old) in 1989 and 1995 — Uganda Source: UNAIDS 2001.

  9. Substantial and Sustained Risk Reduction in Urban Males Visiting Sex Workers 1990–1997 — Thailand Sources: Sittitrai et al, Thongthai et al, Chamratrithirong et al. Need dates

  10. Modes of Transmission • Sexual – most common mode of transmission globally • Risk per episode • Receptive vaginal intercourse: 0.1–0.2% • Receptive anal intercourse: 0.1–3% • Insertive vaginal intercourse: 0.1% • Insertive anal intercourse: 0.06% • Receptive oral intercourse: 0.04%

  11. Factors Affecting Sexual Transmission of HIV Source: Royce et al 1997.

  12. Modes of Transmission continued • Parenteral • Transfusion: 95% risk of infection with single unit of whole blood • Injection drug use: 0.67% risk per exposure • Healthcare workers (needlestick): 0.4% risk per exposure

  13. Modes of Transmission continued • Perinatal • 25–30% risk of transmission without antiretroviral therapy or scheduled cesarean section • Traditional practices • Circumcision, ear piercing, tattooing, ritual scarification with shared and non-sterile or non-disinfected instruments

  14. Modes of Transmission continued HIV is NOT transmitted by: • Insect bites • Kissing • Hugging • Touching toilet seats • Sharing eating utensils

  15. HIV Prevention – What Works? • Voluntary counseling and testing (VCT) • Risk assessment • Risk reduction • Testing • Behavioral interventions to reduce risk behavior • Condoms (dual protection or dual use) • Sexually transmitted infection (STI) prevention and treatment

  16. HIV Prevention – What Works?continued • Antitretroviral (ARV) and breastfeeding interventions to prevent mother-to-child transmission (MTCT) • Safe transfusion practices

  17. Reasons to Provide HIV Counseling and Testing • Knowledge of HIV status can benefit HIV-infected persons • Treat and prevent opportunistic infections • Prevent of MTCT • Reduce risk of transmission to others • Help plan for future • Provide access to antiretroviral therapies as these become available • HIV prevention counseling is effective at reducing risky behaviors in HIV-infected and uninfected persons

  18. Behavioral Interventions • Education • Recognition of risks • Recognition of barriers to risk reduction • Motivation to change • Risk reduction plan

  19. Age < 25 yrs Single Sexual behavior: woman or partner More than one partner in last 3 months Multiple partners New or casual partner Mobile population Refugee Husband in military or long-distance truck driver STIs: woman or partner History Signs or symptoms History of substance abuse Pregnant History of tuberculosis (TB) Sex worker Signs or symptoms suggesting HIV Risk Assessment

  20. Ways to Reduce Risk of Transmission • Sexual behavior • Abstain from or delay start of intercourse • Decrease number of sexual partners • Practice monogamy • Practice non-penetrative sex • Avoid: • Anal sex • Douching • Dry sex • Sex during menses • Sex while using alcohol/drugs • Use condoms with every sexual act

  21. Condoms • Most effective method to prevent HIV transmission and STI acquisition • Male and female condoms available • Clients should be instructed in proper use • Consistent use must be emphasized Male Condom Female Condom

  22. Percentage of Sexually Active Men and Women Who Have Ever Used a Condom, Urban Uganda, 1989 and 1995 Source: UNAIDS 2001.

  23. Dual Protection • Dual protection: Protection against pregnancy, HIV and other STDs • Achieved by: • Avoidance of penetrative sex • Mutual monogamy between non-infected partners using effective contraception • Condom use alone • Dual method: Condom use in combination with other contraceptives

  24. Dual Protection continued • Used correctly and consistently with every act of sex, condoms are 98% effective in protecting against HIV and STDs and 95–97% effective in preventing pregnancy

  25. Female Condom versus Male Condom Source: UNAIDS 2000.

  26. 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

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

  28. 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.

  29. 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

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

  31. 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

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

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

  34. 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

  35. 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

  36. MTCT Transmission with Short Course Oral ARV Regimens

  37. 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

  38. 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

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

  40. 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

  41. 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

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

  43. 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

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

  45. 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.

  46. 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.  

  47. 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. 

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