Prevention with Positives: Theory into Practice

1. Prevention with Positives: Theory into Practice Joseph McGowan, MD Sanjiv Shah, MD North Shore University Hospital May 2007 Please do not reproduce without permission of authors: sshah2@nshs.edu

2. Other Resources • Prevention in Positives: A Case Based Workshop for Providers (Shah, McGowan and Young, 2005) • New York/New Jersey AIDS Education and Training Center (http://www.nynjaetc.org/)

3. Case Presentation • 43 year old female, diagnosed with HIV and HCV in 2004. • CD4 count is > 500 and VL 45,000, ART naïve. • Married last year to her partner of 3 years who tested HIV negative 4 months ago. Partner is aware of patient’s HIV positive status. • They are sexually active and do not use condoms.

4. Case Presentation (2) • Patient’s partner believes that since they have been sexually active for 3 years and he has not contracted HIV by now, there is little chance of him getting HIV at this point. • Both partners have expressed the concept that women can’t spread HIV readily to men • What type/frequency of sexual activity do the couple engage in? • Should the patient start treatment now to lower her risk of transmission in spite of her high CD4 count? • How can HIV risk behavior be reduced in a monogamous relationship?

5. Background • Persons with HIV infection are the source of HIV transmission in the community • Transmission occurs from both those who know their serostatus and those who are unaware • Risk of transmission may increase as prevalence of HIV rises due to stable infection rate and decreased mortality

6. Background: HIV Transmission among Known Seropostives • Potentially greater risk of transmission of multidrug resistant HIV from individuals who know their status, and have virologic failure on antiretroviral therapy • Length of time of seropositivity and perceived health of the individual increases opportunity for transmission (McGowan, et al, CID, 2004) • Research indicates that approximately one third of HIV+ persons engage in behavior that place uninfected individuals at risk for infection (Fisher, J, et al, JAIDS, 2006)

7. HIV Transmission Risk Behavior among Seropositives • Among 3,723 HIV+ individuals (1918 MSM, 978 women, 827 heterosexual men) interviewed in 4 US cities about HIV risk activity within the preceding 3 months: • 44.7% of MSM engaged in unprotected sex (15.6% with HIV-/unknown partner) • 36.5% of women engaged in unprotected sex (19% with HIV-/unknown partner) • 34% of heterosexual men engaged in unprotected sex (13.1% with HIV-/unknown partner) • Estimated 30.4 new infections would be expected among these sex partners in this 3 month period Weinhardt, et al, JAIDS, 2004

8. Sexual Behaviors of HIV+ Men and Women Following Release from Prison • Study conducted within North Carolina State prison system • 64 HIV+ (59% F), scheduled for release within 3 months, agreed to interview within 30-45 days of release • 47% reported having sex after release • 56% with regular partners believed their partners to be HIV-seronegative • 33% with a regular partner reported UPS with HIV-seronegative partners • 44% of the pre-releases were first diagnosed in prison • Secondary risk reduction strategies including lectures given by correctional nurses and health care providers Stephenson BL, et al. Int J of STD/AIDS, Feb 2006

9. Some Factors Affecting HIV Risk Behavior • Rise in STDs among MSMs, linked, in part, to crystal meth use • Decreased concern about HIV transmission risk due to HAART use among HIV+ MSM associated with increased sexual risk taking (Ostrow et al, AIDS, 2002) • HIV transmission behavior among MSM may be linked to spread of HIV to women by “straight” males who engage in undisclosed sex with men (“down low”).

10. Some Factors Affecting HIV Risk Behavior- cont. • High prevalence (41%) of unprotected sex among HIV+ urban patients (mostly heterosexual), especially women (associated with trade of sex for money/drugs) [McGowan, Shah et al, CID, 2004] • History of sexual trauma, drug and alcohol abuse, and homelessness associated with increased high-risk sexual behavior among women (HIV+/HIV-) in Los Angeles. (Paxton et al, AIDS Behav, 2004)

11. HAART Use and HIV Transmission Risk • HAART use has been associated with reduced fear of HIV mortality and increased sexual risk behavior among MSM and urban men and women [Miller AIDS 2000, Stolte AIDS 2004, Van de Ven AIDS 2005, McGowan, CID 2004]. • Meta-analysis of 25 studies on HAART and high risk behavior for HIV transmission found that while there was no association of increased UPS with HAART use or with having an undetectable viral load, there was an increase in UPS among subjects who believed that HAART was protective against HIV transmission [Crepaz, JAMA 2004]

12. HAART Use and HIV Transmission Risk • Attitudes toward health risks and perceived susceptibility to disease may affect both adherence to HAART and HIV transmission risk behavior [Wilson, CID 2002] • HIV prevention interventions should be implemented to educate patients initiating HAART on their potential to transmit HIV, including drug resistant virus [CDC, NYSDOHAI].

13. High Risk Behavior Among HIV Seropositives- Lessons Learned • Complacency regarding safe sex practices- patient and medical provider- “Prevention Fatigue”. Prevention efforts should be ongoing- not just at the initial/annual visit • Misconception of risk, especially if viral load is low. Acknowledge that although risk of transmission is less with low VL, it is not eliminated • Untreated STD can lead to increased local shedding of HIV in genital tract. Vigilant STD screening should be part of our prevention efforts • Substance use, socioeconomic factors, and mental illness underlie HIV transmission behavior. Providers should know their patients and address the issues that may contribute to ongoing risky behavior (e.g. drug rehab, psychiatric care, entitlements, supportive services).

14. Lessons Learned- IDU • Significant decline in HIV infection prevalence among IDUs entering BIMC detox program. • Decline observed in males and females, and long- and short-term drug users. • Potential reasons: • Access to clean needles • “Informed altruism”: knowledge of serostatus may impact behavior • “Partner restriction”: sharing of “works” confined to a small network of contacts • Risk elimination may not be necessary to curtail the epidemic within a population Des Jarlais, et al, JAIDS, 2004

15. Can High Risk Sexual Behavior Among HIV+ be Reduced? • HIV Testing of all “at risk” persons and engagement of all seropostives into care • Rapid HIV Testing • Opt out testing in certain STD clinics in TX. • Routine screening for STDs • Heightened awareness for medical providers of risk behavior rates • Education about impact of high risk behavior for HIV+ individuals themselves and their contacts • Counseling intervention to impact on high risk behavior- role of “Motivational Interviewing Techniques”

16. CDC Revised Recommendations for HIV Testing in Health-Care Settings • HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). • Persons at high risk for HIV infection should be screened for HIV at least annually. • Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. • Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. • HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.Repeat screening in the third trimester is recommended in high-prevalence areas. MMWR: September 22, 2006 / 55(RR14);1-17

17. Role of Universal HIV Testing and Prevention • In a meta-analysis of findings from eight studies, the prevalence of unprotected anal or vaginal intercourse with uninfected partners was on average 68% lower for HIV-infected persons who were aware of their status than it was for HIV-infected persons who were unaware of their status. • HIV testing must be accompanied by linkage to HIV specialty care. Marks, J Acquir Immune Defic Syndr 2005;39:446--53.

18. HIV Super-infection • Now well described based on dual infections with different clade virus and presence of circulating recombinant forms. • Intra-subtype super-infection is not readily apparent but may occur in up to 15% of patients (Taylor and Korber, Infect Genet Evol, 2005) • “Serosorting” may not lead to new HIV infections, but may increase the risk of HIV superinfection, STDs and spread of drug-resistant virus • Risk of HIV super-infection may be a potent stimulus for behavior change (“Loss Frame” safer sex message).

19. HIV Serosorting • Partner selection and condom use • Many studies among MSM have shown increased odds for UAI among HIV concordant vs discordant partners • Imperfect prevention strategy: 15- 30% of new HIV cases occurring among MSM who report having UAI only with HIV – sex partners (i.e. partners who said they were negative) [Golden, M, CROI, 2006] • Serosorting does not prevent new bacterial STDs

20. Case Presentation • 26 year old male, HIV+, CD4 50, VL 300,000, he has MDR HIV and has been on multiple ART regimens and is now on “salvage” treatment. • He is sexually active with men but feels that it is the responsibility of his partners to initiate condom use. He will use condoms only if asked. Does not disclose HIV status to his partners.

21. Case Discussion • What is your reaction to the patient’s attitude toward safer sex? • At a recent PIP workshop, a physician stated that what this patient was doing was bordering on “criminal behavior”. What do you think? Would this effect your approach to the patient? • Gains in reducing HIV transmission due to ARV use can be offset by behavioral changes that increase HIV transmission risk

22. What Does Not Work • Ignoring the problem (missed opportunities to address unsafe sex practices- Viagra Rx, testosterone replacement, pregnancy, STDs, etc) • Being judgmental or condescending (“Blame and Shame”) • Passing the Buck (“It’s not my job, the social worker will deal with it”) • Prudishness- If we are not comfortable discussing or knowledgeable about sexual risk (especially across straight/gay perspectives) and drug use practices, how can we engage our patients to change?

23. Counseling Received at That Day’s Visit: CAPS HRSA Study 37% 42% 33% 25%

24. Physicians and the Safer Sex Message • Physicians were more likely to provide HIV risk reduction counseling to newly diagnosed HIV + patients than established patients (60% vs 14%) [Richardson J, CROI, 2006]

25. Plan for Success • Engagement in care (SAFE)- increased HIV testing of all at risk and engagement of positives in care (and counsel the negatives in how to remain negative) • Incorporation of HIV transmission risk reduction into primary HIV care (Site specific) • Use of a multidisciplinary team approach to reinforce the message and funnel feedback from all sources • Establishment of an open, non-judgmental environment that fosters discussion and disclosure (start in the waiting room with leaflets, condoms in exam rooms) • Continuous re-engagement, reinforcement to avoid fatigue

26. Techniques to Encourage Behavior Change • Recognize behavior change as a continuous, evolving process moving toward a desired goal • Utilize Motivational Interviewing Techniques to stimulate the patient to change behavior • The desire for change must come from the patient. The provider can marshal the discussion, but the patient must feel in charge. • In the end the patients should feel they have done it themselves.

27. Techniques to Encourage Behavior Change • Be careful not to validate unsafe behavior, the goal should always be to reduce risky practices. • Negotiate and escalate: Essence of harm reduction • Don’t be discouraged by relapses • Open ended questions: “Tell me about the people you’ve had sex with recently” vs. “Are you having sex?”

28. Essentials of Motivational Interviewing • Express Empathy • Develop Discrepancy • Roll with Resistance • Support Self-Efficacy

29. Case Presentation • 46 year old male, uses methamphetamines, has had multiple male casual sexual contacts that he met at various clubs, recently diagnosed HIV+. He states he had a negative HIV test approximately 1 ½ years prior. • Initial VL was 250,000 and CD4 count was 80. • How would you address partner notification in this case? • What other prevention issues may be relevant? Screening for STDs. HIV drug resistance testing. Sexual risk taking in the context of methamphetamine use (especially if boosted by ART use).

30. Challenges • Behavior change is difficult. Sexual practices are difficult to modify • How do we confront our own attitudes toward behavior which we find objectionable • How do we address risk behavior in HIV-serodiscordant relationships? • How do we train, motivate and sustain the prevention effort…among patients AND PROVIDERS

31. Clinician-Delivered Prevention Message • Fisher JD et al (JAIDS, 2006): Significant reductions in UP events (vaginal and anal intercourse, insertive oral sex) over 18 month period • 2 HIV clinics: Intervention in one clinic, SOC in the other • CASI: to assess sexual and IDU behaviors. Baseline and 3 more times at 6 month intervals • 5-10 minutes at each clinical encounter using motivational interviewing techniques • “Prevention prescription”

32. Clinician-Delivered Prevention Message • 497 patients participated in the study • Baseline: 23% reported unprotected vaginal, anal or insertive oral sex during preceding 3 months • Estimated mean unprotected sexual events: intervention arm: 7.15 (BL) vs. 1.53 (18 mos) SOC: 2.06 vs. 9.61 • Caution: provider fatigue (“boosting”), staff turnover (attendings, residents, ID fellows)

33. Clinician-Delivered Prevention Message • Loss frame safer sex message may be more effective than gain frame prevention message (Richardson J, CROI, 2006) • Loss frame: “if you smoke you may get lung cancer” • Gain frame: using condoms will keep your partner free of getting HIV or other STDs. • Loss frame: negative consequences of UPS, for example: STDs, HIV superinfection.

34. Prevention Workshop • http://www.nynjaetc.org/curriculum/Preventionbook.pdf Please do not reproduce without permission of authors: sshah2@nshs.edu