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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 !!!!!!!
31 y/o F dx HIV+ 2000
Viral Load
Cd4 (%)
Oct 2000
371,862
11 (1)
Feb 2001
1,267
289 (10)
Mar 2001
<400
298 (8)
May 2001
3,220
188 (9)
Jan 2000 Start D4T/3TC/Nelfinavir
May 2001 Geno / Pheno Type Ord 7,276

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
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
High Risk Sex
 Procreation
 Behavioral
 Alcohol/Substance Abuse
 Intimacy
 Guilt/Empathy
 Unprepared/Uneducated
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)
HIV Epidemic in US
Through 2001 – 816K AIDS cases
(CDC)
White
Black
Hispanic
MSM
70%
30%
37%
IDU
13%
39%
38%
MSM/IDU
8%
6%
6%
Hetero
7%
23%
17%
Other
3%
2%
2%
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
HIV Mucosal Transmission
Cell free virus or cell-associated ????
 Seminal
plasma
 Endocervical swab specimens
 Cervicovaginal lavage samples
HIV Transmission
 Method
of Sexual Intercourse
 Viral Load in Blood
 Advanced Stage of Disease
 Primary Infection
 HIV Clade
 Initial Sexual Contacts
HIV Transmission
 Foreskin
 Cervical
ectopy
 Menstruation
 Immune activation
 Genital Ulcers
 Genital tract trauma
Transmission Probability
Infectivity per Contact
Female  Male
Male  Female
Male  Male
0.0002 – 0.008
0.0008 – 0.009
0.0009 – 0.085
Needle Stick
Needle Sharing
Mother  Infant
Mother  Infant (AZT)
0.002 – 0.0095
0.009
0.2 – 0.3
0.08 – 0.10
M. Cohen and J. Enron, Sexual HIV Transmission and Its
Prevention, Jan 2002 (Medscape)
Transmission Probability
Concentration of HIV in Plasma is a
Important Determinant
Uganda
Viral Load
<3,500
>50,000
Risk
1/10,000
5.1/1000
Gray et al. Lancet 2001,357:1149-1153
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
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%)
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%)
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 nonmain partners during vaginal sex in past 3
months
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
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
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
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
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)
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
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%)
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)
 Feb
2003 –
 Requests
VL 61
Tcell= 241 (14)
Sildenafil (Viagra) ….
 Evaluation
for Impotence
Sildenafil always given with CONDOMS
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
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
Prevention Initiative
February 2001 – CDC launches S.A.F.E.
(Serostatus Approach to Fighting HIV Epidemic)
1.
2.
3.
4.
5.
Encourage voluntary testing
Improve access to to healthcare if HIV +
Provide appropriate therapy
Emphasis on Adherence
Promote safer sexual behavior
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
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
• 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
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
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)
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
HIV + male, HIV - Female
 Educate
Client
 Explore Options
 Girlfriend
presents to clinic
 HIV Testing
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
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
High Risk for Transmission
• Adherent to Clinic appts
• Refuses ARV
• Psychiatry evaluation
• ONGOING discussion on Condom use
• MDI Case Conference
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
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
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)
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
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
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
Discussing Disclosure of HIV
Stein M. and Samet J.
AIDS Patient Care and STD. 1999;13:265-7
 Express empathy for the difficulty of
choosing disclosure
 Have Patient state Pros and Cons
 Avoid argument to convince by force or
moral argument
 Describe successful disclosures you, as a
clinician have facilitated