Download HIV Prevention

Care of Women with HIV Living
in Limited-Resource Settings
Prevention
Jean R. Anderson, MD
Director
Johns Hopkins HIV Women’s Health
Program
1
Resources
A Guide to the Clinical Care of Women With
HIV: 2001 First Edition
To request the guide, send e-mail to
[email protected]
Care of Women With HIV Living in LimitedResource Settings tutorial series
For more information about the HIV tutorial
series, send e-mail to [email protected].
2
Learning Objectives
Why prevention is important
Progress made in HIV prevention
Modes of HIV transmission
Most effective interventions for reducing
transmission
3
Performance Objectives
Explain why prevention is important
Demonstrate progress made in HIV
prevention
Discuss the modes of HIV transmission
Describe the most effective interventions for
reducing transmission
4
Risk Perception: Percentage of
Sexually Active Women (15–19)
Who Think They Are not at Risk of
Getting AIDS
Guatemala
Brazil
Niger
Chad
Mali
Togo
Haiti
Kenya
Uganda
Zambia
Zimbabwe
87%
52%
87%
60%
46%
45%
63%
36%
21%
52%
50%
0
Source: UNICEF 1999
20
40
60
Percentage
80
100
5
Risk Perception: Percentage of
Sexually Active Women (15–19)
Who Think They Are not at Risk of
Getting AIDS
Guatemala 1%
Brazil 1%
52%
1%
Niger
Chad 2%
60%
3%
Mali
46%
7%
Togo
45%
10%
Haiti
63%
16%
Kenya
36%
19%21%
Uganda
27%
Zambia
52%
30%
Zimbabwe
50%
0
Source: UNICEF 1999.
20
40
60
Percentage
87%
87%
HIV prevalence
rate in women
attending
antenatal care
clinics in major
urban areas
(at time of
survey)
80
100
6
Trends in HIV Prevalence in
Selected Populations
Kampala, Uganda, < 20 year old antenatal clients1
Thailand, 21 year old military conscripts2
HIV prevalence (%)
25
Dakar, Senegal, all ages antenatal clients1
20
15
10
5
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Source: 1National STD/AIDS Control Programmes; 2Armed Forces Research Institute
of Medical Sciences
7
Percentage Sexually Experienced by
Current Age (15–24 years old) in
1989 and 1995 — Uganda
% Sexually Experienced
100
75
Women 1989
Men 1989
Women 1995
Men 1995
50
25
0
15
16
17
18
19
20
21
22
23
24
Age
Source: UNAIDS 2001.
8
% Visiting Sex Workers
in 12 months
Substantial and Sustained Risk
Reduction in Urban Males Visiting Sex
Workers 1990–1997 — Thailand
50
45
40
35
30
25
20
15
10
5
0
1990
1993
1997
Age 20-24
Age 25-29
Sources: Sittitrai et al, Thongthai et al, Chamratrithirong et al. Need dates
9
Modes of Transmission
Sexual – most common mode of
transmission globally
Risk per episode
Receptive vaginal intercourse: 0.1–0.2%
Receptive anal intercourse: 0.1–3%
Insertive vaginal intercourse: 0.1%
Insertive anal intercourse: 0.06%
Receptive oral intercourse: 0.04%
10
Factors Affecting Sexual
Transmission of HIV
Infectiousness
Susceptibility
Late Clinical Stage
N/A
Primary HIV Infection
N/A
Antiretroviral Therapy
?
Genital Tract Infection
Cervical Ectopy
?
Circumcision
Method of Contraception
Barrier
Hormonal
?
Spermicidal
?
IUD
?
Menstruation
Pregnancy
Source: Royce et al 1997.
?
?
11
Modes of Transmission
continued
 Parenteral
Transfusion: 95% risk of infection with single unit
of whole blood
Injection drug use: 0.67% risk per exposure
Healthcare workers (needlestick): 0.4% risk per
exposure
12
Modes of Transmission
continued
Perinatal
25–30% risk of transmission without
antiretroviral therapy or scheduled cesarean
section
Traditional practices
Circumcision, ear piercing, tattooing, ritual
scarification with shared and non-sterile or nondisinfected instruments
13
Modes of Transmission
continued
HIV is NOT transmitted by:
Insect bites
Kissing
Hugging
Touching toilet seats
Sharing eating utensils
14
HIV Prevention – What Works?
Voluntary counseling and testing (VCT)
Risk assessment
Risk reduction
Testing
Behavioral interventions to reduce risk
behavior
Condoms (dual protection or dual use)
Sexually transmitted infection (STI)
prevention and treatment
15
HIV Prevention – What Works?
continued
Antitretroviral (ARV) and breastfeeding
interventions to prevent mother-to-child
transmission (MTCT)
Safe transfusion practices
16
Reasons to Provide HIV
Counseling and Testing
Knowledge of HIV status can benefit HIVinfected persons
Treat and prevent opportunistic infections
Prevent of MTCT
Reduce risk of transmission to others
Help plan for future
Provide access to antiretroviral therapies as
these become available
HIV prevention counseling is effective at
reducing risky behaviors in HIV-infected and
17
uninfected persons
Behavioral Interventions
Education
Recognition of risks
Recognition of barriers to risk reduction
Motivation to change
Risk reduction plan
18
Risk Assessment
 Age < 25 yrs
 Single
 Sexual behavior:
woman or partner
More than one partner in
last 3 months
Multiple partners
New or casual partner
 Mobile population
Refugee
Husband in military or
long-distance truck
driver
 STIs: woman or
partner
History
Signs or symptoms
 History of substance
abuse
 Pregnant
 History of tuberculosis
(TB)
 Sex worker
 Signs or symptoms
19
suggesting HIV
Ways to Reduce Risk of
Transmission
Sexual behavior
Abstain from or delay start of intercourse
Decrease number of sexual partners
Practice monogamy
Practice non-penetrative sex
Avoid:
Anal sex
Douching
Dry sex
Sex during menses
Sex while using alcohol/drugs
Use condoms with every sexual act
20
Condoms
Most effective method to prevent HIV
transmission and STI acquisition
Male and female condoms available
Clients should be instructed in proper use
Consistent use must be emphasized
Male Condom
Female Condom
21
Percentage of Sexually Active Men
and Women Who Have Ever Used a
Condom, Urban Uganda, 1989 and
1995
% Ever-Used Condoms
70
60
50
Women 1989
Men 1989
Women 1995
Men 1995
40
30
20
10
0
15-19
20-24
25-39
40-49
All
Age Groups
Source: UNAIDS 2001.
22
Dual Protection
Dual protection: Protection against
pregnancy, HIV and other STDs
Achieved by:
Avoidance of penetrative sex
Mutual monogamy between non-infected
partners using effective contraception
Condom use alone
Dual method: Condom use in combination with
other contraceptives
23
Dual Protection continued
Used correctly and consistently with every
act of sex, condoms are 98% effective in
protecting against HIV and STDs and 95–
97% effective in preventing pregnancy
24
Female Condom versus Male
Condom
Male Condom
Female Condom
Made from latex; some also from polyurethane
Made from polyurethane
Fits on the penis
Loosely lines the vagina
Lubricant:
 Can include spermicide
 Should be water-based only for latex
 Located on the outside of condom
Lubricant:
 Can include spermicide
 Can be water-based or oil-based
 Located on the inside of condom
Covers most of the penis and protects the woman’s
internal genitalia
Latex condoms can decay if not stored properly;
polyurethane condoms are not susceptible to
deterioration from temperature or humidity
Covers both the woman’s internal and external
genitalia and the base of the penis
Polyurethane condoms are not susceptible to
deterioration from temperature or humidity
Condom must be put on an erect penis
Can be inserted prior to intercourse - does not
require erect penis
Does not need to be removed immediately after
ejaculation
Can be safely reused if washed, rinsed and air
dried after initial use
Must be removed immediately after ejaculation
Should not be reused
25
Source: UNAIDS 2000.
Protection Against HIV Offered
by Other Contraceptive
Methods
Spermicides
May have activity against gonorrhea,
chlamydia
Possible increase in mucosal irritation
and genital ulcers, especially with
frequent use
Recent UNAIDS clinical trial of sex
workers in Africa and Thailand found
significantly higher HIV seroconversion
rates in nonoxynol-9 users as
compared to a placebo vaginal lubricant
26
Protection Against HIV Offered
by Other Contraceptive
Methods continued
Diaphragm
No significant protection against
HIV transmission
Limited STI protection
27
Protection Against HIV Offered by
Other Contraceptive Methods
continued
IUD
No STI or HIV protection
Increased menstrual flow and
duration with nonprogesterone
containing IUDs may increase
transmission risk and risk of anemia
No increase in cervical HIV shedding
four months after insertion.
28
Source: Richardson 1999.
Contraception and Prevention of
HIV Infection continued
Hormonal methods: oral
contraceptive pills, DMPA, Norplant
implants
No significant STI or HIV protection
May increase genital tract HIV
shedding
Voluntary sterilization
No STI or HIV protection
Decreased risk of PID
29
STIs — Prevention and
Treatment
STIs, both ulcerative and nonulcerative, facilitate HIV
transmission 2–5 fold
Condoms
Sexual behavior change
Recognition of risk factors and early
symptoms
Syndromic management
Genital ulcer disease
Urethral discharge in men
Vaginal discharge – limitations
30
STIs – Prevention and Treatment
continued
Antenatal screening for syphilis
Linkage to programs treating symptomatic
men
Target high-risk individuals
Sex workers and clients
Drug users
Military personnel
Truck drivers
31
Rates of STIs Among Pregnant
Women in Dakar, Senegal,
1991–1996
35
STD Prevalence (%)
30.1
30
1991 (n = 511)
25
1996 (n = 540)
20
18.1
15
11.9
10
7.5
6.7
4.4
5
2 0.9
0
Trichomonas
vaginalis
Source: UNAIDS 2001.
Chlamydia
trachomatis
Neisseria
gonorrhoeae
Syphilis
32
Comparison of Increase in
Condom Use with Decline in
Reported Male STIs on a National
Scale, Thailand, 1989–1994
65
180
Male STDS
Condom Non-use
160
140
120
55
45
35
100
80
25
60
15
40
5
20
0
-5
1989
Source: UNAIDS 2001.
% of Sex Acts Not
Protected by Condoms
Reported Male STDs (in 1000s)
200
1990
1991
1992
1993
1994
33
Ways to Reduce Risk of
Transmission
Injection drug use
Offer drug treatment
Avoid sharing or reusing needles or other injection
equipment or supplies
Offer needle exchange programs
OR
Clean injection equipment with high-level
disinfection of needles and syringes by soaking in
0.5% bleach or boiling for 10 minutes
Use boiled water to prepare drugs or equipment
Clean injection site before injection
34
Safely dispose of syringes after use
Ways to Reduce Risk of
Transmission
Traditional Practices
Avoid female circumcision – may increase risk of
trauma or bleeding with intercourse
Do not share sharp instruments used in ritual
cutting, tattooing practices
OR
High-level disinfect instruments after each use
35
MTCT Transmission with Short
Course Oral ARV Regimens
Site
Regimen
MTCT
Reduction
No Breastfeeding
Thailand
ZDV: 36 weeks, labor
50%
ZDV: 36 weeks, labor
37%
(3 months)
ZDV: 36 weeks, labor,
postpartum (mother)
38%
(6 months)
ZDV/3TC: 36 weeks, labor,
postpartum (mother &
newborn)
52%
(6 weeks)
ZDV/3TC: labor, postpartum
(mother & newborn)
38%
(6 weeks)
NVP (single dose): labor,
postpartum (newborn)
47%
(4 months)
Breastfeeding
Côte d’Ivoire
Uganda,
Tanzania,
South Africa
Uganda
36
Preventing MTCT in LowResource Settings —
Breastfeeding
 HIV-negative women or women with
unknown HIV status
Breastfeed exclusively for 6 months
Reinforce use of condoms during
breastfeeding
 HIV-positive women
Avoid if safe and affordable alternatives
available
Teach proper attachment of newborn to
nipples and frequent breast emptying
Seek prompt treatment of mastitis or
breast abscess and oral thrush in
newborns
Breastfeed exclusively for up to 6 months
Photo by: Hugh Rigby, Kenya, 1982
37
Prevention — TransfusionRelated
Prevent or treat causes of anemia and blood
loss
Malnutrition
Malaria
Parasitic infestation
Pregnancy (repeated pregnancies at short
intervals, postpartum hemorrhage)
Minimize unnecessary transfusions: Use
blood substitutes (crystalloid /colloid) for
volume replacement when possible
38
Prevention — TransfusionRelated continued
Select donors carefully: Family replacement
and paid or professional donors higher risk
Screen blood supply
39
Barriers to Prevention for
Women
Stigma of HIV
Women often unaware of partner’s infection
status or level of risk
Women may be unable to negotiate safer
sex practices
Sexual coercion
Domestic violence
Economic vulnerability
40
Prevention Lessons Learned
Focusing on high-risk groups is not enough
Risk behavior and vulnerability should be
emphasized
Knowledge and awareness are important but
not sufficient
Life skills training (sexual negotiation)
Condom promotion
Long-term change in social norms
41
Prevention Lessons Learned
continued
Socioeconomic interventions to reduce
vulnerability are needed
Education of girls
Protection of human rights
Reduction of stigma
42
Antiretroviral Therapy and
Prevention
ARV for HIV-infected persons:
Reduces risk of sexual transmission
Reduces incidence of TB
Promotes HIV testing
Barriers
Complex regimens
Resistance issues
Side effects and toxicity
Cost
43
HIV Prevention — Future
Research
Microbicides
Postexposure prophylaxis
Vaccines
44
References
1.
2.
3.
4.
5.
6.
Anderson J. HIV and reproduction. In Anderson J (ed): A Guide to
the Clinical Care of Women with HIV. HRSA/DHHS, 2001.
Armed Forces Research Institute of Medical Sciences. Thailand.
Chamratrithirong et al. Review of the 100% Condom Programme,
Mahidol University. 2001.
Compendium of HIV prevention interventions with evidence of
effectiveness. Centers for Disease Control and Prevention, National
Center for HIV, STD, and TB Prevention, Division of HIV/AIDS
Prevention, Atlanta, Georgia. November 1999.
Consultation on STD interventions for preventing HIV: What is the
evidence? UNAIDS. May 2000.
Female condom-guide for planning and programming. UNAIDS.
August 2000.
45
References continued
7.
HIV prevention needs and successes: a tale of three countries.
UNAIDS. May 2001.
8.
HIV prevention strategic plan through 2005. Centers for Disease
Control and Prevention. January 2001.
Institute of Medicine. No time to lose: getting more from HIV
prevention. September, 2000
9.
Male condom technical update. UNAIDS. September 2000.
National STD/AIDS Control Programmes. Senegal and Uganda.
10. Richardson BA, Morrison CS, Sekadde-Kigondu C, et al. Effect of
intrauterine device use on cervical shedding of HIV-1 DNA. AIDS
13:2091-7, 1999.
11. Royce RA, Sena A, Cates W Jr, and Cohen MS. Sexual
transmission of HIV. N Engl J Med 336:1072-8, 1997.
12. Sex and youth: Contextual factors affecting risk for HIV/AIDS.
UNAIDS. May 1999.
46
References continued
13. Sittitrai W, Phanuphak P, Barry J, et al. A survey of Thai sexual
behaviour and risk of HIV infection. Int J STD AIDS (England), SepOct 1994, 5(5) p377-8.
14. Sweat M, Gregorich S, Sangiwa G, et al. Cost-effectiveness of
voluntary HIV-1 counselling and testing in reducing sexual
transmission of HIV-1 in Kenya and Tanzania. Lancet
2000;356:113-121.
15. Thongthai et al. Media Effectiveness Survey. Mahidol University.
2001
16. UNICEF, DHS surveys, 1994-1999.
17. The voluntary HIV-1 Counseling and Testing Efficacy Study Group.
Efficacy of voluntary HIV-1 counselling and testing in individuals
and couples in Kenya, Tanzania, and Trinidad: a randomized trial.
Lancet 2000;356:103-112.
18. Wang C and Celum C. Prevention of HIV. In Anderson JR (ed): A
Guide to the Clinical Care of Women with HIV. DHHS, HRSA, HAB.
47
Washington, D.C. 2001.