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Sexual Risk Reduction with HIV Positive Adults

Sexual Risk Reduction with HIV Positive Adults. SANEESE STEPHEN, RPA-C, MPAS CENTER FOR H.O.P.E. KINGS COUNTY HOSPITAL. Why are we so concerned. About SEXUAL BEHAVIOR?. HIV positive persons are living longer…and guess what?. They are having SEX !!!!!!!.

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Sexual Risk Reduction with HIV Positive Adults

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  1. Sexual Risk Reduction with HIV Positive Adults SANEESE STEPHEN, RPA-C, MPAS CENTER FOR H.O.P.E. KINGS COUNTY HOSPITAL

  2. Why are we so concerned About SEXUAL BEHAVIOR?

  3. HIV positive persons are living longer…and guess what? They are having SEX !!!!!!!

  4. JUNE 2001 START TRIZIVIR/INDINAVIR/NORVIR 800-100 • JULY ‘01-MARCH ‘02 VL = 153-441 • APRIL 2002 VIRAL LOAD < 50, T-CELL= 209 (10) • AUGUST 2002 VL= 791, TCELL = 242 (12) • SEPTEMBER 2002 : 4-5 WKS PREGNANT, VL=682 • DEC 2002: VL=648 FEB 2003: VL=478

  5. Resistant HIV Johnson VA, et al. J Infectious Disease. 2001;183:1688-1693 • Infant with proviral DNA with evidence of RT mutations (M41L, L74V, and T215Y) and 3 PR substitutions (K20R, M36I and V82A) • Mother’s proviral DNA had same substitutions • Confirmation for Vertical transmission of MDR HIV

  6. High Risk Sex • Procreation • Behavioral • Alcohol/Substance Abuse • Intimacy • Guilt/Empathy • Unprepared/Uneducated

  7. HIV Epidemic in US/NYS • 1n 1999, 84% of residents diagnosed with AIDS were people of color (minorities) • Of Total AIDS cases in US 56.6% are Minorities 78% Women 82% Children • NYS accounts for >25% of all reported AIDS cases among women in the US of which 31.8% due to heterosexual contact • As of 6/2000, 19% on nation’s total AIDS cases were in NYS (140,000)

  8. HIV Epidemic in USThrough 2001 – 816K AIDS cases (CDC)

  9. Sexual Transmission • Most common route of HIV transmission in the world (75%) Probability of Transmission 1. Infectiousness of Index case 2. Mode of Sexual Contact 3. Susceptibility of Person Exposed

  10. HIV Mucosal Transmission Cell free virus or cell-associated ???? • Seminal plasma • Endocervical swab specimens • Cervicovaginal lavage samples

  11. HIV Transmission • Method of Sexual Intercourse • Viral Load in Blood • Advanced Stage of Disease • Primary Infection • HIV Clade • Initial Sexual Contacts

  12. HIV Transmission • Foreskin • Cervical ectopy • Menstruation • Immune activation • Genital Ulcers • Genital tract trauma

  13. Transmission Probability Infectivity per Contact Female  Male 0.0002 – 0.008 Male  Female 0.0008 – 0.009 Male  Male 0.0009 – 0.085 Needle Stick 0.002 – 0.0095 Needle Sharing 0.009 Mother  Infant 0.2 – 0.3 Mother  Infant (AZT) 0.08 – 0.10 M. Cohen and J. Enron, Sexual HIV Transmission and Its Prevention, Jan 2002 (Medscape)

  14. Transmission Probability Concentration of HIV in Plasma is a Important Determinant Viral Load Risk Uganda <3,500 1/10,000 >50,000 5.1/1000 Gray et al. Lancet 2001,357:1149-1153

  15. High Risk Sexual Behavior • Younger Age • Low Education Level • History of STD • Drug or Alcohol Use During Sex • Depression • Engage in Oral or Anal Sex • Partner did not have AIDS

  16. Sexual Behavior Risk Assessment – Stephen S (2000) HIV positive persons attending SUNY Brooklyn (N=150) Mean Age = 38.4 years SD = 8.5 Women = 89 (59.3%) Men = 61 (40.7%) BK (72%), HP (14.7%), MD (6.0%), WT (5.3%), Single (64%), Married (16%), Other (18%)

  17. Sexual Behavior Risk Assessment – Stephen S (2000) Sexual Partner in Past 3 Months Men (n=61): 45(73.8%) Women(n=89): 60(67.4%) Main Partner: Men 33(54%) Women 45(50%) NonMain Partner: Men 12(19.6%) Women 15(16.9%)

  18. Sexual Behavior Risk Assessment – Stephen S (2000) High Risk Sexual Behavior (HRSB) • 31.9% of patients practice HRSB with main partner during vaginal sex in past 3 months • 31.8% of patients practice HRSB with non-main partners during vaginal sex in past 3 months

  19. Sexual Behavior Risk Assessment – Stephen S (2000) Disclosure to sexual partners • 51% of men and 60% of women always disclose HIV+ status • 24% of men and 21% of women never disclose HIV+ status

  20. High Risk Sexual Behavior • Margolis et al. AIDS 2001 • Survey of 250 HIV infected gay men in SF • 37% reported recent unprotected anal sex with potentially uninfected partner • 23.3% of men reported that health care provider had never spoken to them about safer sex

  21. High Risk Sexual Behavior Elford et al 1999 • more than 33% of gay men are less concerned about HIV infection with advances in treatment Remien et al 1999 • HIV + gay men more likely to have unprotected sex since they believe that they are longer infectious with HAART

  22. High Risk Sexual Behavior Van de Ven P et al (1999) • Association with unprotected anal intercourse and optimism with new HIV Rx Miller et al (2000) • No significant increase in HRSB with initiation of HAART Wilson et al (2001) • ART may be associated with increased risk behavior in HIV+ minority women

  23. Resistant HIV Little SJ, et al Antiviral Therapy 2001. Abs 25 8th Conf. on Retro & Opport Infect (2/01) • 389 tx-naïve subjects from 9 NA cities • 16. 5% of subjects with >10 fold reduced susceptibility to one or more ARVdrugs (4.6% in previous report, p=0.002) • Multi-drug resistance (two or more classes) increased from 1 to 6% (p=0.01)

  24. Resistant HIV UK Collaborative Group BMJ. 2001;332:1087-1088 • 14% of 69 newly infected patients had one or more key HIV-1 mutations Briones C (Madrid, Spain) J Acquired ID Syndrome.2001;26:145-150 • 26.7% of 30 newly infected patients had genotypes with reduced susceptibility

  25. Feb ’02 – 37 yo BM, bisexual, recently tested HIV+, h/o oral thrush. Male partner recently died of HIV illness.. VL= 15, 876 T cell= 21 (2%) March ’02 – Start Trizivirr April ’02 – Treated for Rectal Herpes. VL= <400, T cell = 51 (4%) June ’02 – Treated with Cryotherapy for HPV VL= 684, T cell= 90 (5%), misses 2-3 doses/month July ’02 – VL 6, 508 and T cell = 79 (4%)

  26. Aug ’02 – Genotype Collected RT: M41L, M184V, L210W, T215Y (Reduced susceptibility to all NRTI) PI: L10L/I, M46L, L63P, L90M (Reduced susceptibility to IDV, NFV, RIT, SQV) Sep ’02 – Start Lopinavir,Viread, Videx, Efavirenz, and Combivir (13 pills daily)

  27. Feb 2003 – VL 61 Tcell= 241 (14) • Requests Sildenafil (Viagra) …. • Evaluation for Impotence Sildenafil always given with CONDOMS

  28. HIV Superinfection XIV Int. AIDS Conf. Barcelona, Spain • Dr. Bruce Walker: studies with STI • Control of low level viremia with increased CD8 T cell CTL responses • Superinfection by second Clade B virus differing by 12% caused loss of control

  29. Postexposure Prophylaxis CDC and Expert panel recommends PEP 28 day course of HAART regimen • Needle Stick Exposure • High Risk Sex • Rape Cardo et al NEJM 1997;337:1485-1490 CDC Guidelines for STD Treatment MMWR 1998

  30. Prevention Initiative February 2001 – CDC launches S.A.F.E. (Serostatus Approach to Fighting HIV Epidemic) • Encourage voluntary testing • Improve access to to healthcare if HIV + • Provide appropriate therapy • Emphasis on Adherence • Promote safer sexual behavior

  31. Sexual History • Initial History: HIV risk factor • Sexual Partners • History of abuse, or rape • Drug/EtOH use during sexual activities • History of GC/Chl, Syphilis, HPV, HSV • Condom Use history, last 3 months, last sexual encounter

  32. 34 y/o BF dx HIV+ in 1999 • Baseline VL =16, 135 Tcell=702 (32%) • 3 HIV- children • HIV+ Partner (on treatment) • June 2002, 9 wks Pregnant

  33. History of 5 VTOP • Further discussion reveals EtOH abuse • Partner is inconsistent with condom use • Social Work, Health Educator, Nursing • Admitted to Alcohol Abuse Treatment Program, continues to attend meetings

  34. Sexual Education/Discussion • Avoid medical jargon • Provider comfortable about discussions will facilitate Patient discussion • Medical /Psychological history if patient is not sexually active • Contraception, and Family Planning • Condoms are covered by Medicaid

  35. Talking About Safer Sex • Prevention First • Develop Trust • Communicate about Sexuality • Communicate the Risks • Identify Related Factors • ON GOING DISCUSSIONS M. Cohen and J. Enron, Sexual HIV Transmission and Its Prevention, Jan 2002 (Medscape)

  36. 28 y/o HP male dx 2000 • Baseline VL 26,948 T cell = 248 • Denies current sexual activity • Started on HAART • VL <50, Tcell > 600 • Returns to work and has girlfriend • Interested in having child

  37. HIV + male, HIV - Female • Educate Client • Explore Options • Girlfriend presents to clinic • HIV Testing

  38. Behavior Changes • Sexual Abstinence • Sexual Monogamy • Proper and Consistent Condom Use • Early Treatment of STD • Adherence to ARV for Maximal Suppression of HIV Viral Load

  39. 43 y/o BM dx HIV + 1996 • Highly Experienced to HAART • History of NonAdherence • Poor toleration of Meds • Highly Resistant to 3 Classes of ARV • VL >500K, Tcell 20-80 • Sexually active with multiple women

  40. High Risk for Transmission • Adherent to Clinic appts • Refuses ARV • Psychiatry evaluation • ONGOING discussion on Condom use • MDI Case Conference

  41. Power of Condoms • HIV acquisition reduced by 50-100% in men who use condoms in 10 cohort studies • De Vincenzi et al. NEJM 1994 123 Discordant couples in Europe • Deschamps et. Ann IM 1996 1 of 42 infections with consistent condom use 7-14% infection with inconsistent use

  42. Smoking Cessation • Provider initiated behavioral change method is affective for smoking cessation • Pieterse M, et al. Preventive Medicine 32(2):182-90. 2001 February • Easton A, et al. Women and Health 32(4):77-91, 2001

  43. Behavioral Intervention Shain et al (1999) • Randomized trial of 424 Mexican women and 193 African American women • Intervention of three small group sessions of 3-4 hour sessions • Retention of 89% of sample at end of 12 months • Intervention group had significantly lower rates of GC, Chlamydia at 6 mos (p=0.05), second 6 mos (p=0.008) and over entire 12 month study period (p=0.004)

  44. Behavioral Intervention Kalichman et al (2001) • Randomized trial of 232 men and 99 women with HIV from ID clinics in Georgia • 5 session group intervention and followed for six months post intervention • Intervention group at 6 months had significantly lower reported Unprotected vaginal/anal intercourse (P<.01) • Demonstrated HIV risk-transmission reduction

  45. Partner Notification • NYS Regulation on June 1, 2000 • PN to get newly exposed/infected patients into medical care • De crease spread of HIV • Data for planning and funding of care • Mandatory for spouses • Options for Self-Notification or Deferral

  46. Disclosure of HIV Status • Benefits of early diagnosis and treatment • Potential to limit the spread of HIV through education and counseling • Consequence of abuse, separation with partner who may be sole provider of financial and emotional support • Stigma with HIV diagnosis is still present

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