Download Diagnoses of HIV Infection among Adults and

HIV Basics for Health Educators
Taylor Starr DO, MPH
Division of Adolescent Medicine
Department of Pediatrics
Golisano Children’s Hospital
The University of Rochester School of Medicine and Dentistry
2015
Learning Objectives
•Define HIV and AIDS and related medical terminology
•Explain modes of transmission of HIV
•Describe epidemiology of HIV in the US and NY
•Explain the most current HIV screening recommendations
•List prevention strategies for HIV
•Explain Pre-exposure Prophylaxis (PrEP) and Post-exposure
Prophylaxis (PEP)
•Understand consenting for HIV treatment
•Access resources for testing and treatment in NY State
2
Definitions
Human Immunodeficiency Virus
•Single stranded RNA retrovirus
•Copies itself
•Attacks and destroys infectionfighting CD4/T-cells
Acquired Immunodeficiency Syndrome (AIDS)
•The most advanced stage of HIV
infection
•Defined by:
•CD4 cell count below 200
• opportunistic infections that are
AIDS defining
3
Terminology
CD4 Count
Viral Load
•Types of white blood cells that HIV
infects
•Polymerase Chain Reaction (PCR)
• Measure HIV RNA
• RNA is the part of the virus that
knows how to make more virus
•These cells help fight infection and
disease
•Marker for susceptibility to
opportunistic infections
•In a healthy (non-infected) immune
system, CD4 counts range from
5000-1800
•Below 200 defines AIDS
•Marker of disease progression
•Monitors therapeutic response
•Goal of therapy: undetectable,
below 50 copies
4
HIV: CD4 Count and Viral Load
5
Based on Figure 1 in Pantaleo, G et al. (February 1993). "New concepts in the immunopathogenesis of human
immunodeficiency virus infection". New England Journal of Medicine 328 (5): 327-335. PMID 8093551.
Modes of Transmission for Adolescents
•Sexual
• Oral, Vaginal, Anal
•Needle Sharing (and sharing drug
paraphernalia)
• Drug use
• Tattoos
• Body piercing
• Steroids
•Maternal-Child (vertical transmission)
6
High Concentration of HIV
Not associated with transmission
• Blood
• Tears
• Semen
• Nasal secretions
• Vagina/cervical secretions
• Saliva
• Breast Milk
• Sputum
• Internal Body Fluids:
• Brain/spinal fluid
• Heart (pericardium)
• Lungs
• Joints
• Abdominal Organs
• Fetus (amniotic)
• Perspiration
• Urine
• Feces
• Vomit
7
Vertical Transmission
•In-utero:
• During course of pregnancy
•Intra-partum:
• At the time of labor and delivery
• Believed to be the time in which 50-70% of transmission occurs
•Post-partum:
• Through breastfeeding
8
Probability of Transmission: Source is HIV Infected
Exposure: Sexual Intercourse Risk of Transmission
Female to Male
1 in 700 to 1 in 3000
Male to Female
1 in 200 to 1 in 2000
Male to Male
1 in 10 to 1 in 1600
9
Royce RA et al NEJM 1997; 1072-1078
Relative Risk of HIV Infection according to Type of Behavior
Exposure
Risk/10,000 Exposures
Needle sharing
67
Receptive anal intercourse
10-30
Receptive vaginal intercourse
8-20
Insertive vaginal intercourse
3-9
Insertive anal intercourse
3
Oral sex with ejaculation
Conflicting data-likely low risk
10
Dosekun O, Fox J (July 2010). "An overview of the relative risks of different sexual behaviours on HIV transmission.".
Current opinion in HIV and AIDS
Boily MC, Baggaley RF, Wang L, Masse B, White RG, Hayes RJ, Alary M (February 2009). "Heterosexual risk of HIV-1
infection per sexual act: systematic review and meta-analysis of observational studies.". The Lancet infectious diseases 9
(2): 118–29.
HIV in the United States 2010: snapshot
• Youth (13-24) made up 17% of the US population
• All new HIV infections:
• Youth accounted for an estimated 26%
• MSM (men who have sex with men) 72%
• Black : 57%
• Hispanic/Latino :20%
• White 20%
11
http://www.cdc.gov/hiv/risk/age/youth/index.html?s_cid=tw_std0141316
Rates of Diagnoses of HIV Infection among Adults and
Adolescents, 2013—United States and 6 Dependent Areas
N = 47,958
Total Rate = 18.0
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have
been statistically adjusted to account for reporting delays, but not for incomplete reporting.
Estimated: New HIV Infections in the US, 2010:
The Most Affected Subpopulations
13
http://www.cdc.gov/hiv/statistics/basics/ataglance.html
Diagnoses of HIV Infection among Adults and
Adolescents, by Sex, 2009–2013—United States
and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have
been statistically adjusted to account for reporting delays, but not for incomplete reporting.
Rates of Diagnoses of HIV Infection among Adults
and Adolescents, by Age at Diagnosis, 2009–2013
—United States
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically
adjusted to account for reporting delays, but not for incomplete reporting. Rates are per 100,000 population.
Diagnoses of HIV Infection among Adults and
Adolescents, by Age at Diagnosis, 2013—United
States
N = 47,165
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been statistically adjusted to
account for reporting delays, but not for incomplete reporting.
Diagnoses of HIV Infection among Adults and
Adolescents, by Transmission Category,
2009–2013 — United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Diagnoses of HIV Infection among Adults and
Adolescents, by Sex and Transmission Category, 2013—
United States and 6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays and missing transmission category, but not for incomplete reporting.
a Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
b Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
Diagnoses of HIV Infection among Adults and Adolescents,
by Sex and Race/Ethnicity, 2013—United States and
6 Dependent Areas
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have been
statistically adjusted to account for reporting delays, but not for incomplete reporting.
a Hispanics/Latinos can be of any race.
Estimated: New HIV Infections in the US, 2010:
The Most Affected Subpopulations
20
http://www.cdc.gov/hiv/statistics/basics/ataglance.html
Summary of US Statistics: 2010
AGE:
• 13 to 24 year olds accounted for an estimated 26% of all new HIV infections
RACE/ETHNICITY
• African Americans are the racial/ethnic group most affected by HIV
BEHAVIORS:
• Most new HIV infections among youth occur among MSM
• MSM account for most new infections among African Americans
• PUTTING IT ALL TOGETHER:
• MSM ages 13 to 24 are the most affected of this group
• Among all MSM, African Americans are the racial/ethnic group most affected by HIV
• Among MSM Young African American MSM accounted for the highest number of new
21
HIV infections
http://www.cdc.gov/hiv/statistics/basics/ataglance.html
NYS: Newly Diagnosed HIV and AIDS Cases, 2012
Including Prisoners
Excluding Prisoners
Ryan White Region
HIV
AIDS
HIV
AIDS
Albany
77
64
72
55
Binghamton
13
13
12
12
Buffalo
112
75
108
72
Lower Hudson
125
91
121
85
Mid Hudson
42
40
41
35
Nassau/Suffolk
183
123
179
119
Rochester
92
60
85
56
Syracuse
87
58
84
48
Total
731
524
702
482
Bureau of HIV/AIDS Epidemiology
AIDS Institute
New York State Department of Health
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NEW YORK STATE (Excluding NYC)
HIV cases (excluding prisoners), Newly Diagnosed 2012: by Sex, Age, Race/Ethnicity and Risk
Males
#
%
#
%
531
100
171
100
13-19
18
3.4
3
1.8
20-24
101
19
18
10.5
25-29
75
14
13
7.6
30-39
11
20.9
42
24.6
40-49
116
21.8
51
29.8
White
202
38
37
21.6
Black
159
29.9
89
52
Hispanic
117
22
27
15.8
Asian/PI
7
1.3
4
2.3
Native Am
2
0.4
14
8.2
Total
Age at Dx
Race/Ethnicity
Females
Multi race
Risk
MSM
362
68.2
IDU
14
2.6
12
7
Heterosexual*
31
5.8
157
91.8
Adolescents are at higher risk
•Behavioral
• Sex
• MSM
• Experimentation with alcohol/drugs
•Biological (factors contributing to heightened infection rate among women):
• Pubertal changes: columnar cells replaced by squamous cells
• STIs are transmitted more efficiently from M to F
• Mechanics and larger surface area of female genital tract
• STIs are more likely to remain asymptomatic in F
•Socioeconomic
• Poverty
• Lack of access to care
• Education
• Prevention skills
24
Transgender communities:
among the groups at highest risk for HIV infection
•Lack of familial support
•Violence
•Stigma and discrimination
•Limited health care access
•Negative health care
encounters
•Higher rates of drug and alcohol
abuse
•Sex work
•Incarceration
•Homelessness
•Untreated Mental Health Needs
•Unemployment
25
CDC Recommendations for Universal Testing
2009 Change to NYS Testing Law
•Required that an HIV related test be offered every
individual between the ages of 13-64:
• In-patient
• Emergency department
• Primary care services in out-patient part of a hospital
• Freestanding diagnostic and treatment centers
26
Screening and Prevention
Recommendations
• HIV Testing should be:
• Offered to all persons 13 and 64 at least once
• Offered annually to persons whose behavior indicates elevated risk
• sexual activity or drug use
• Offered every 3 months for patients with high risk behaviors:
• unprotected anal sex
• multiple or anonymous sexual partners
• needle-sharing partners
• For high-risk patients, the focus should be on continued education, behavioral
counseling, and harm reduction
• Risk-reduction counseling: education about safer sex practices, condom use,
safer injection practices, referral to syringe exchange programs
27
http://www.health.ny.gov/diseases/aids/providers/testing/law/docs/updates.pdfrug treatment services.
When youth ask who should be tested…..
• Have had sex with someone who is HIV-positive or whose status is unknown since their
last HIV test
• Have injected drugs (including steroids, hormones, silicone) and shared needles and
syringes with others
• Have exchanged sex for drugs, shelter, money
• Have been diagnosed with or sought treatment for a sexually transmitted disease
• Have been diagnosed with or sought treatment for hepatitis or tuberculosis
• Have had sex with someone who could answer yes to any of the above questions or
someone whose history they don’t know
28
http://www.cdc.gov/hiv/basics/testing.html
HIV Time Course
29
Based on Figure 1 in Pantaleo, G et al. (February 1993). "New concepts in the immunopathogenesis of human immunodeficiency virus infection". New England Journal of Medicine 3
HIV Screening
•Seroconversion: immune system takes 3 to 8 weeks to make antibodies
against HIV
•Tests differ in how early they are able to detect antibodies
•Most HIV tests look for these antibodies, some look for the virus itself
•The window period: period after infection but before the test becomes positive
•Deciding when to get tested therefore depends on when you may have been
exposed and which test is used.
•97% will develop antibodies in the first 3 months after infected
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How soon after exposure to HIV can tests detect the virus?
Even among antibody tests, the window period varies
• “first-generation” and “second-generation” :
• detect one type of HIV antibody.
• On average, they can detect antibodies 42-60 days after infection.
•third-generation” tests:
• detect all types of antibodies, which makes them more sensitive
• These assays can detect antibodies about 21-24 days after infection.
•“fourth-generation” tests
• simultaneously detect both HIV antibodies and antigens
• Tests that look for the p24 antigen can detect it within 14-15 days.
• Tests can detect plasma HIV RNA (ribonucleic acid) within about 10 days
of infection.
http://www.hivguidelines.org/clinical-education/hiv-qa-fact-sheets/window-period-for-hiv-infection/
31
32
HIV Testing in Non-Clinical Settings
•HIV tests can be administered in community-based organizations and
even in mobile clinics by certified personnel.
•HIV testing in these non-clinical settings offers an effective way to bring
HIV testing to the community.
LIST of CLIA-WAIVED RAPID HIV TESTS
(suitable for use in non-clinical settings):
http://www.cdc.gov/hiv/pdf/testing_ListNonClinicalSettings.pdf
33
PREVENTION: Things to think about
• Low perception of risk
• Low rates of testing
• Low rates of condom use
• High rates of sexually transmitted infections (STIs)
• Older partners
• Substance use
• Homelessness
• Inadequate HIV prevention education
• Feelings of isolation.
34
HIV Prevention Strategies
•Abstinence
•Vaccination: Hepatitis B and HPV
•Mutual Monogamy
•Reducing the number of sex partners
•Avoid drugs and alcohol
•Condoms
•Dental dams
•Use a water based lubricant
•Avoid sex with anyone who has symptoms of an STD
•Avoid sex with anyone who uses IV drugs
•Regular STD screening for all partners
35
Pre-exposure prophylaxis (PrEP)
•In 2012: FDA approved Truvada as pre-exposure prophylaxis (PrEP)
•HIV PrEP: six-point program that includes taking one pill once a day to
prevent an uninfected person from becoming infected with HIV
• Clinical trials: when an uninfected person takes the medication
consistently, the chance of becoming infected HIV is greatly reduced
•Truvada must be prescribed by a qualified medical provider.
36
NY State Clinical Guidance
PrEP as an HIV/STD prevention option
•gay man or trans-woman who has unprotected anal intercourse
•in a sexual relationship with a partner who has HIV
•trans-person who has unprotected anal or vaginal sex
•trade sex for money, drugs or housing
•inject drugs or share injection equipment
•use stimulant drugs such as methamphetamine and have unprotected
sex
•have had more than one STD in the last year; or,
•have taken HIV post-exposure prophylaxis more than twice in the last
year.
37
The six-point PrEP program
1.
HIV testing: to make sure the person was not recently infected with
HIV
2.
3.
Taking one Truvada pill, once a day, every day for a specific
period of time
Using condoms to prevent STDs
4.
Periodic STD screening
5.
Education about how to reduce the risk of getting HIV and STDs
through sex
6.
Counseling and support for taking the medication regularly
(adherence)
38
What are the side effects of PrEP?
•Truvada is recognized as a well-tolerated medication with
few side effects.
•The main side effect is mild nausea
•Only a small number of people found the side effects
serious enough to stop taking the medication
•Lab tests to monitor kidney functions every six months are
part of the medical protocol for PrEP
39
How often are the medical appointments for PrEP?
• Initial Appointment: education about PrEP, a discussion about readiness to take PrEP, HIV
testing and, if ready, medication is prescribed for an initial 30-day period
• One Month Follow-Up: the provider will discuss your experience on PrEP including
adherence, side effects and interest in continuing. At this visit, a prescription for 60 days may
be given.
• Three Month Follow-Up: HIV testing and STD screening are conducted. The provider will
review the importance of adherence and provide support for taking the medication every day.
At this visit, a prescription for 90 days may be given.
• Every Three Months: HIV testing and other assessments are repeated every three months. If
remain HIV negative and express continued commitment to take the medication daily, a
prescription for 90 days may be given every three months
40
How well does PrEP work?
•The PrEP medication works very well at preventing HIV
infection
•It is most effective when taken every day
•It is not recommended that a person start and stop the
PrEP medication based on when he or she anticipates
engaging in unprotected sex
• A person considering PrEP should only begin once he or
she has made a commitment to taking the medication daily
41
Paying for PrEP?
•Medicaid and many private health insurance plans will cover the cost of
PrEP.
•A medication assistance program is also available from the drug
manufacturer to help those who do not have any health coverage
•Prior approval is granted for three months at a time and must be
renewed in order for Medicaid to continue paying for the medication
•With private health insurance, check the plan to see if PrEP is covered
•Gilead also offers a medication assistance program for eligible adults
who do not have insurance: http://www.truvada.com/truvada-patientassistance or call 1-855-330-5479
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Post Exposure Prophylaxis (PEP)
•FOR: people exposed to HIV during a single event (e.g., during episodes of
unprotected sex, needle-sharing injection drug use, or sexual assault)
•TO: try to reduce the chance of becoming HIV positive
•BY: taking anti-HIV medications as soon as possible after exposure to HIV
• PEP must begin within 72 hours of exposure
• PEP consists of 2-3 antiretroviral medications prescribed for 28 days
• PEP is safe but may cause side effects like nausea in some people
• These side effects can be treated and are not life threatening
43
Who pays for PEP?
•If prescribed PEP after sexual assault:
• may qualify for partial or total reimbursement for medications and clinical
care costs through the Office for Victims of Crime funded by the U.S.
Department of Justice
• If prescribed PEP for another reason:
• healthcare provider can help apply for free antiretroviral medications
through the patient assistance programs of the drug manufacturers.
44
https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/post-exposure-prophylaxis/
PrEP and PEP Providers
•In an effort to increase access to HIV pre-exposure prophylaxis (PrEP)
and post-exposure prophylaxis (PEP), the New York State Department
of Health AIDS Institute (NYSDOH AI) has compiled a list of providers
that prescribe PrEP/PEP:
https://www.health.ny.gov/diseases/aids/general/prep/docs/directory.pdf
45
Vertical Transmission Prevention
Greatly lower risk of transmitting HIV from 20 to 1% by:
• Getting tested for HIV when planning a pregnancy or
+ pregnancy test
• Taking antiretroviral drugs during pregnancy, labor, and
delivery
• Having a C-section
• Avoiding breastfeeding
• Newborns are given medicine to further protect them
46
Recommendations: while pregnant
•Medication should be given to ALL pregnant HIV infected
women
•Preferred: zidovudine (AZT) in combination with lamividine
(Combivir)
•Goal: achieve undetectable HIV-1 RNA levels prior to
delivery
•Resistance testing
47
Can HIV-infected minors consent for their own
treatment?
•
NYS Public Health Law Section 2504, parental or guardian
consent is required for a physician to treat a minor for HIV/AIDS,
including in school-based clinics
•Family planning clinics can provide only family planning related
care to minors with the minor’s consent
•Minors who are married or pregnant/parenting can consent for
their own care
48
https://www.health.ny.gov/diseases/aids/providers/testing/law/faqs.htm
http://www.hivguidelines.org/clinical-guidelines/adolescents/hiv-disclosure-to-parents-and-consent-to-hiv-treatment-among-adolescents/
Clinical Judgment
• When it is medically necessary to initiate antiretroviral therapy (ART) for a minor who will not
disclose to his/her parent or legal guardian and the minor understands his/her condition,
including the risks, benefits, and treatment options, every effort should be made to engage the
patient in a dialogue with the goal of disclosure to parents or legal guardians.
• Although parental or legal guardian consent should be obtained before initiating ART, the
clinician may not disclose confidential HIV-related information if, in the judgment of the
clinician, the disclosure would not be in the best interest of the minor.
• Such a disclosure may also jeopardize the patient-provider alliance, as well as the patient’s
future acceptance of care.
49
http://www.hivguidelines.org/clinical-guidelines/adolescents/hiv-disclosure-to-parents-and-consent-to-hiv-treatment-among-adolescents/
Key Points: Minors who are HIV positive
• Adolescent may be at risk for abuse if they disclose their HIV
status.
• Appropriate referrals and assistance should be offered to patients
reporting such risks.
• Discussions about disclosure and possible risks to the adolescent
should be documented in the medical record.
• Coordination with insurance companies is necessary to ensure
that confidentiality is managed according to patients’ wishes.
50
Treatment for HIV
•called antiretroviral therapy (ART)
•can dramatically prolong the lives of people
infected with HIV and lower their chance of
infecting others
•provides a nearly normal life expectancy to
someone diagnosed with HIV and treated before
the disease is far advanced
51
Resources: HIV Screening and Treatment
•http://gettested.cdc.gov/
• (free fast confidential testing)
•health.ny.gov/diseases/communicable/std/
clinics/clinics.htm
•National STD hotline (1-800-232-4636)
52
STD Clinics in New York State: by county
https://www.health.ny.gov/diseases/communicable/std/clinics/clinics.htm
https://www.health.ny.gov/diseases/communicable/std/clinics/
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