Department of Health and Human Services Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral H

1. Department of Health and Human Services Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Integrating HIV Prevention into Care and Treatment:Four Key Strategies Pamela Bachanas, PhD Atlanta, GA September 2007

2. Positive Prevention • Scale up of care and treatment programs have been an extraordinary success • PEPFAR has assisted in putting 1.1m people on ART, but 4.1m new infections took place in the last year • Multiple approaches to prevention are needed; integration of prevention into care and treatment settings is critical • To have a significant impact on slowing the spread of the epidemic, prevention efforts must also be directed toward individuals living with HIV who can transmit the virus • Basic infectious disease epidemiology suggests we limit spread of HIV from its source

3. Positive Prevention in Care and Treatment • Due to increasing availability of HIV treatment, many HIV+ persons are accessing health care settings and clinics, providing an opportunity to reach a large number of infected persons with prevention messages and interventions • For any disease, preventive information on infection control delivered by the provider is regarded as quality standard of care • Positive prevention interventions should be both behavioral and biomedical

4. Positive Prevention Goals 1. Reduce sexual transmission of HIV to partners by: • Increasing disclosure of HIV status to partners • Testing partners (and children/family) of HIV+ patients • Identifying discordant couples • Reducing number of sex partners • Abstaining or using a condom during every sexual encounter • Diagnosing and treating STIs in HIV+ persons and partners • Counseling on lower risk ways to become pregnant 2. Identify HIV+ partners/family members for care and treatment

5. Positive Prevention Goals (cont.) 3. Reduce risk of patient acquiring new infections - STIs and new strains of HIV 4. Reduce unintended pregnancy and MTCT 5. Reduce alcohol use that contributes to high risk transmission behaviors and poor adherence 6. Reduce viral load through increasing adherence to care and treatment

6. What services must be available to achieve these goals?

7. 1. Partner Testing and Assistance with Disclosure

8. Risk of Sero-Discordance • Transmission from an HIV infected spouse or cohabitating partner accounts for a large proportion of new HIV infections in Africa • For example, DHS & AIS data show that majority of HIV infected persons are married in Kenya (70%), Malawi (82%), & Uganda (57%) • Sero-negative partners in discordant couples are the largest single risk group for HIV

9. High Rates of Sero-Discordance • In Zambia and South Africa, approximately 20% of couples in the general population were found to be discordant (Lurie et al., 2003; McKenna et al., 1997). • In Kenya, 50% of spouses of HIV-infected persons are HIV negative (450,000; DHS, 2003) • In Botswana, of people who came into VCT center for testing because their partner was HIV positive, 57% were negative (Tebelopele, 2007) • Of discordant couples tested in Botswana at Tebelopele, 51% were married or cohabitating (Tebelopele, 2007)

10. Low Rates of Partner Testing • Rates of partner testing among HIV+ patients is often low: In Uganda: • 54% of spouses of HIV+ patients participating in an ARV program had never been tested (Mulongo & Wasagami, 2006) • 99% of HIV- spouses of HIV+ patients on treatment had never been tested (Were et al. 2006). In Kenya: • 40% of a cohort of ART patients did not know their partner’s status • 40% of a cohort of patients on cotrim did not their partner’s status (Luchters, et al., 2006) • *Data from PEPFAR 6/06 Meeting in Durban, SA

11. Disclosure • Disclosing HIV status to partners may facilitate HIV prevention behaviors (partner testing, treatment adherence, condom use). • Disclosure rates are low in developing countries. • 19 Developing countries: Only 49% of women disclosed their HIV status to regular sexual partners (WHO, 2004) • Tanzania: 40% of a cohort of 1078 women disclosed their HIV status during 4 yrs of follow-up (Antelman et al., 2001) • Kenya: 20% of ART patients and 20% of those on preventive therapy had disclosed their status to their partner (Luchters et al., 2006)

12. What’s needed… • Providers must assess whether each patient’s partner has been tested and refer to counselor for testing (and/or disclosure assistance) • Counselor who can conduct rapid testing available in care and treatment clinic • Discordant couples identified and counseled • Positive partners linked to care and treatment • Negative partners counseled on prevention practices to stay negative (condoms!) • Children of HIV+ mothers tested and linked to care if positive • Condoms in clinics and distributed by providers

13. 2. STI Management Integrated into HIV Clinics

14. STIs and HIV Transmission • In HIV+ individuals, STIs have been shown to increase genital HIV shedding, increasing likelihood of HIV transmission. • Genital ulcer disease has the strongest association with HIV transmission and acquisition; urethritis, vaginitis, and bacterial vaginosis have also been associated with transmission and acqusition. • STIs have been associated with increased genital HIV shedding in persons on ARVs with suppressed plasma viral loads (Cohen, unpublished).

15. 5 4 3 2 AIDS Acute Infection 3 wks STD Episode STD Episode Viral Load and STIs HIV RNA in Semen (Log10 copies/ml) (Cohen and Pilcher, JID 2005)

16. HSV-2 and HIV • High HSV-2 co-infection among HIV+ individuals. • In women, HSV-2 prevalence and incidence was associated with increased risk of HIV acquisition (Brown, et al, 2007). • In Burkina Faso, women with HIV-1 and HSV-2 treated with valcyclovir suppressive therapy had decreased genital HIV-1 RNA compared with placebo (Nagot, NEJM, 2007). • Currently awaiting data on transmission studies; several RCTs underway.

17. Management of STIs:Where we should be • Diagnostic lab testing • Baseline RPR on all women of childbearing age • Exams on all patients to r/o ulcers, rashes and other STIs • Symptomatic treatment of HSV2 • ?Suppressive therapy for HSV2 • Drugs available in ARV pharmacies

18. Management of STIs:Where we are starting • Training & IEC materials on syndromic management of STIs in HIV+ individuals and their sex partners are being developed and adapted from WHO and ITECH materials for health care providers in HIV clinics • HIV providers trained to incorporate evaluation and treatment of STIs into routine HIV care by: • Taking clinical history for STI symptoms • Performing a baseline physical examination on all males and on high risk women (or all women if feasible) to r/o ulcers, rashes and other STIs • Diagnosing STI syndrome and treating, using local MoH guidelines • Encouraging STI disclosure and partner treatment

19. 3. Basic Family Planning Services Provided in HIV Care and Treatment Clinic

20. Family Planning • Many women on ARVs resume sexual activity and have unintended pregnancies (Bunnell et al., 2006) • Preventing unintended pregnancy in HIV+ women who do not want children can avert the need for and costs associated with (Sweat et al., 2004) • PMTCT • care for HIV+ children • support for orphans • Other HIV+ women on treatment desire children (Nakayiwa et al., 2006); they require counseling on safe timing of pregnancy and referrals to PMTCT

21. Unmet need for family planning among HIV-infected women(Bunnell, 2007)

22. Four-phase Strategy forPerinatal HIV Prevention Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV-infected women Prevention of transmission from an HIV-infected woman to her infant Support for mother and family Phase 1 Phase 2 Phase 3 Phase 4 Positive prevention focuses on prevention of mother-to-child transmission, with a focus on prevention of unintended pregnancy in HIV-infected women.

23. Family Planning Services:Where we should be • Family Planning nurse integrated into HIV care and treatment setting • Full spectrum of contraceptives offered to HIV-infected women • Counseling on safer pregnancy strategies, PMTCT, and importance of spacing births • Integration of PMTCT services into care and treatment

24. Family Planning Services:Where we are starting • Family planning (FP) materials are being adapted from USAID-supported materials developed by WHO and FHI • Health care providers in HIV clinics trained to inquire about pregnancy intentions every visit and provide basic FP counseling and services • Providers trained to counsel HIV-infected women and their partners who don’t desire pregnancy on dual-protection and they will provide basic contraception services (pills, injections) in HIV care and treatment clinics • Providers also trained to briefly counsel HIV-infected women and their partners who desire pregnancy on safer methods and refer them to PMTCT

25. 4. Lay Counselors in Care and Treatment Clinics

26. Lay Counselors • Given clinic burden and complexity of patients’ needs, many patients need more in-depth counseling on prevention issues (e.g. partner testing, disclosure, alcohol use). Incorporating counselors into clinic settings is essential for a comprehensive prevention program • Training lay counselors to expand and reinforce prevention messages delivered by providers and to provide more in-depth counseling on specific prevention issues is critical for prevention efforts

27. Lay Counselors • Providers refer all HIV+ patients to clinic-based lay counselors for enhanced prevention counseling • HIV+ patients meet individually with lay counselors (most HIV-positive) before or after each clinic visit • Counselors trained to: • Reinforce prevention messages and strategies • Discuss barriers and aid in problem-solving for prevention-related issues • Screen for alcohol use and conduct brief intervention • Perform VCT with partners/family • Discuss basic family planning options and refer to provider/family planning nurse for services • Discuss medication adherence • Provide condoms and demonstrate use • Refer for additional counseling or intervention services if needed

28. Positive Prevention in Community and Home-Based Settings • In addition to clinic settings, community-based and home-based care settings offer important venues for prevention interventions for HIV-infected people • Prevention messages and strategies for HIV-infected persons can be included in VCT, counseling sessions, support groups, or peer-led interventions, or interventions delivered through home-based care • Often HIV+ individuals are not only beneficiaries of these programs but also are actively involved in their development and implementation

29. Positive Prevention in Community and Home-Based Settings • Home –based care providers can access multiple family members with prevention messages and can refer or test partners and children • These programs should have strong linkages to clinics and should share prevention messages and materials for consistency • Can adapt clinic-based model to home-based setting

30. Acknowledgements Annie Bollini, Ph.D. Catherine McLean, MD Jan Moore, Ph.D. Melissa Poulsen, MPH Nora Rosenberg, MSPH

31. Thank you!