Download HIV Prevention in Clinica Care

HIV Prevention in
Clinical Care
Allen McCutchan, MD, MSc
Professor of Medicine, UCSD
Jose Burgos, MD
UCSD, UABC, COLEF, SDSU
Overview of Lecture
To reduce transmission of HIV by their patients medical
care providers can:
1. screen and counsel HIV-infected patients for risk behaviors, by
– discussing sexual and drug-use behaviors
– communicating prevention messages
– reinforcing changes to safer behavior
2. refer patients for services such as,
– substance abuse treatment
– partner counseling and referral and
3. identify and treat other sexually transmitted infections that
increase HIV transmission
4. recommend circumcision to uncircumcised men
A clinical study shows the value and effect of these
interventions.
Different Scenarios
• What should the approach be on a patient
attending an office visit on different
scenarios:
– A patient with newly-diagnosed HIV infection
comes to a physicians office for initial
evaluation.
– Patient with stable chronic HIV infection and
Sexual transmitted disease (STD)?
– chronic, stable HIV and not complaints
coming for a routine visit.
Principles
• HIV-infected patients:
– in clinical care are the source of a large number of
new cases of HIV infections
– who are not treated with HAART and continue unsafe
sex are most likely to transmit HIV
• HIV expert medical providers:
– have strong influence on their patients
– see them in clinic regularly
– can ask them about their behavior and deliver brief
counseling if needed
– need training and support to accomplish their role in
prevention
Recommendations for screening HIV-infected
patients for HIV transmission risk.
• Sponsors/authors
–
–
–
–
–
Centers for Disease Control and Prevention (CDC),
Health Resources Services Administration (HRSA),
National Institutes of Health (NIH),
HIV Medicine Association (HIVMA)
Infectious Diseases Society of America (IDSA)
• Publication: CDC’s Morbidty and Mortality Weekly
Reports (MMWR) 2003; 52(RR-12):1–24.
– Available at http://www.cdc.gov/mmwr/mmwr_rr.html
Recommendations for screening HIV-infected
patients for HIV transmission risk.
• What - behaviors associated with HIV
transmission (A-II)
• How - nonjudgmental history by clinician
or self-report questionnaire
• When - initial visit and minimally once a
year
• Action – any reported risky behavior
prompts more thorough assessment and
discussion of risk reduction
Recommendations for screening HIV-infected
patients for HIV transmission risk.
Strength of recommendation
• A Should always be offered = Both strong evidence of
efficacy and substantial benefit.
• B Should generally be offered = Moderate evidence for
efficacy—or strong evidence for efficacy but only limited
• C Optional = Evidence for efficacy is insufficient
• D Should generally not be offered = Moderate
evidence for lack of efficacy or for adverse outcome
• E Should never be offered = Good evidence for lack of
efficacy or for adverse outcome
Recommendations for screening HIV-infected
patients for HIV transmission risk.
Quality of supporting evidence
• I - Good
– at least 1 properly randomized, controlled trial
• II - Fair
– at least 1 well-designed clinical trial without randomization,
– a cohort or case-con-trolled analytic studies (preferably from 11
center),
– multiple time-series studies;
– dramatic results from uncontrolled experiments.
• III - Minimal
– opinions of respected authorities based on clinical experience,
– descriptive studies, or
– reports of expert committees.
Questions about Sex-related behaviors
•
•
•
•
Is patient engaging in sex?
Number and sex of partners
Partners’HIV status (infected, not infected, or unknown)
Types of sexual activity (insertive or receptive; oral,
vaginal, or anal)
• How often are condoms used
• What are the barriers to abstinence or correct condom
use (e.g., difficulty talking with partners about or
disclosing HIV status, alcohol and other drug use before
or during sex)
• If potentially childbearing, are you pregnant, interested in
becoming pregnant, considering pregnancy or sexually
active and not using reliable contraception
Questions about injection-drug related
behaviors
• Has the patient been injecting drugs?
• Does the patient share needles and syringes or other
injection equipment
• With how many persons does patient share needles
• HIV serostatus of needle-sharing partners (infected, not
infected, or unknown)
• Does the patient use new or sterilized needles, syringes,
and other injection equipment
• What barriers prevent the patient from ceasing illicit drug
use or, failing that, to safer injection practices (e.g., lack
of access to sterile needles and syringes)
Recommendations for screening HIV-infected
patients for HIV transmission risk.
• What - symptoms of STDs (e.g., urethral or
vaginal discharge; dysuria; intermenstrual
bleeding; genital or anal lesions; anal pruritis,
burning, or discharge; and, for women, lower
abdominal pain, with or without fever) (A-I/II)
• How - written or nurse administered patient self
report review of symptoms
• When - Routinely regardless of reported sexual
behavior or other epidemiologic risk information,
• Action - STI signs or symptoms prompt
diagnostic testing with specific lab screening
tests and, when appropriate, treatment.
Recommendations for screening HIV-infected
patients for HIV transmission risk.
• What and how– laboratory screening for STIs
(B-II/III)
– Vaginal exam for women with lab tests for
• cervical chlamydial (<25 years old),
• vaginal trichomonias
– Serology for both men and women
• Syphilis (STS), and
• type-specific antibody for herpes simplex virus,
type 2 (HSV-2)
• When – initial visit and annually if sexually active
or history of STI
• Action – treat appropriately
STIs and HIV Acquisition and Transmission
• Both ulcerative (HSV and syphilis) and
inflammatory (gonorrhea or chlamydia)
STIs increase risk of HIV acquisition
• However, a randomized clinical trial of
syndromic STI treatment failed to reduce
rates of new HIV infections in rural
Uganda
Syndromic management of sexually-transmitted infections and behaviour change
interventions on transmission of HIV-1 in rural Uganda: a community randomised trial.
Kamali, A , Lancet. 2003 Feb 22;361(9358):645-52.
Herpes Simplex Virus – 2 (HSV-2) and risk
of HIV transmission
• Observational studies suggest that + HSV-2
serology is a risk factor for acquisition of HIV by
American MSM (x 2) and for heterosexual
African men (x 6) and women (x 1.3)
• Acyclovir has been associated with decreased
rates of HIV progression in the pre-HAART era
• Suppression of HSV with antiviral drugs is an
untested, but potentially interesting preventive
measure
Recommendations for screening HIV-infected
patients for HIV transmission risk.
• What – pregnancy assessment (possible
current pregnancy, interest in future
pregnancy, or sexual activity without
reliable, contraception) (A-I)
• Who - women of childbearing potential
• How - history and pregnancy testing
• Action - referral for appropriate counseling,
reproductive health care, or prenatal care,
as indicated.
Using clinic environments to support
prevention
• All patients should receive printed information about
– HIV transmission risks and preventing transmission of HIV to
others.
– Information can be conveyed throughout the clinic; for example,
posters and other visual cues containing
• Prevention messages can be displayed in examination
rooms and waiting rooms.
• Materials in Spanish can be obtained through health
department HIV/AIDS and STD programs or from the
National Prevention Information Network (NPIN)
(telephone: 1-800-458-5231; Web site:
http://www.cdcnpin.org).
Circumcision for HIV Prevention
• Observational studies in Africa have shown that
risk of HIV and other STIs (syphilis, chancroid,
and HSV) is reduced by about half (OR = .52) by
circumcision in infancy or adulthood
• A randomized clinical trial has confirmed this
protection (RR=0.40, CI= 0.24–0.68, p = 0.0006)
in 3,274 uncircumcised, HIV-neg, South African
men, aged 18–24 years.
Randomized, Controlled Intervention Trial of Male Circumcision for Reduction
of HIV Infection Risk: The ANRS 1265 Trial; Bertran Auvert et al, PLoS Med.
2005 November; 2(11): e298.
Topics that can be successfully addressed
by clinicians and clinic support staff
• Lack of knowledge about HIV transmission risks
• Misconceptions about risk of specific types of
sexual and drug-use practices
• Misconceptions about viral load and
transmission of HIV
• How to disclose HIV + status to a sex partner,
family member, or friend
• Importance of using condoms and not
exchanging fluids
• Ways to reduce number of sex or drug partners
Topics that can be successfully addressed
by clinicians and clinic support staff
• Ways to obtain support (e.g., emotional,
financial) from family, friends, and lovers
• Ways to keep condoms accessible
• Ways to remember to use condoms
• How to persuade a sex partner to use a condom
• Ways to clean/disinfect injection equipment
• Ways to obtain clean needles
• Ways to avoid sharing injection equipment
• Ways to deal with mild psychological distress
stemming from situational circumstances
Issues that might need referral
to outside agencies
• Need for intensive HIV prevention
intervention
• Excessive use of alcohol or recreational
drug use
• Drug addiction, including injection drug
use
• Depression, anger, guilt, fear, or other
mental health needs
• Need for social support
Issues that might need referral
to outside agencies
• Desire to have children, contraceptive
counseling
• Housing or transportation needs
• Nutritional needs
• Financial emergencies
• Child custody, parole, or other legal
matters
• Insurance
Effect of brief safer-sex counseling by medical
providers to HIV-1 patients:
a multi-clinic assessment
Jean L. Richardson, Susan Stoyanoff, Joel
Milam, Allen McCutchan, Jony Weiss, et al
AIDS 2004, 18:1179–1186
Study Intervention
• Clinic environment contains prevention messages
• Primary medical provider component reinforced at every visit
- Introduce/discuss partnership
- Ask about sexual behavior
- Verbalize prevention messages to patient
- Brief risk-reduction counseling
• Provider initiates a 3 - 5 minute interaction focused on:
– Patient Self Protection
– Partner Protection
– Disclosure of status to sex partners
• Emphasizes the patient/provider partnership
Provider Communication Styles
Gain
Loss
Study Design
Baseline
_______
10-month intervention Follow-up
_________________ ________
Intervention Assess
Assess
Gain Frame
01
[……...…X1………..]
02
Loss Frame
01
[……...…X2………..]
02
Control
01
[……...…X3………..] 02
(Adherence)
Scope of Study
• 6 public HIV Clinics in Southern California
• 9,600 HIV patients received at least 1
intervention session
• 52,000 patient visits in 10-month intervention
period
• 75 primary care providers and over 100 support
staff trained in prevention
Demographic Characteristics of
Follow-up Sample (n=585)
Gender
Male
Female
86%
14%
Sexual Orientation
MSM
Heterosexual men
Heterosexual women
WSW
74%
12%
13%
1%
Ethnicity
White
Hispanic
Black
Other
41%
37%
16%
6%
Results
Unprotected Anal or Vaginal (UAV) Intercourse at Follow-Up
in Patients With 2+ Partners at Baseline
Adjusted OR
UAV at Time 2 Adj for Time 1
Controls
Gain
Loss
95% CI
P
1.00
.81
.42
.36 - 1.82
.21 - .83
.61
.01
UAV Adj. for Multiple Covariates*
Controls
1.00
Gain
1.38
Loss
.42
.51 - 3.75
.20 - .91
.53
.03
*UAV at baseline, age, ethnicity, income, education, viral load, CD4, on
ART, time since testing HIV+
Case Scenario 1.
A patient with newly-diagnosed HIV infection
comes to the clinic for initial evaluation.
• Many things must be addressed during this
initial visit
– medical or psychiatric problems,
– education about HIV,
– history, physical examination, initial laboratory tests
• When and how does one address prevention?
• What is the minimum that should be done, and
how can it be incorporated into this visit?
Conlcusion
• If trained and supported, medical providers
can deliver prevention messages
effectively in the clinic
• Emphasizing “loss” or “negative health
consequences” of unsafe sex reduced the
prevalence of UAV among MSM with initial
risky behavioral profiles
Case Scenarios
• What prevention issues should be
addressed at clinic visits for patient with:
– newly-diagnosed HIV infection coming for
initial evaluation?
– chronic, stable HIV and a new sexually
transmitted infection (STI)?
– chronic, stable HIV and not complaints
coming for a routine visit.
Case Scenario 1
Assuming no emergent issues are present, the following
should be done:
• During the history, question patient about
–
–
–
–
How the patient might have acquired HIV?
What are current risk behaviors?
Who (generically and specific) are current partners?
Have they notified sexual partners and have they been tested for
HIV?
– What are their current symptoms or history of sexually
transmitted infections (STIs)?
• During the physical examination, include genital and
rectal examinations, evaluation and treatment of any
current STI.
• If asymptomatic, perform appropriate screening for STIs
Case Scenario 1
Preventive Interventions
• Discuss
– Current risk behavior
• Emphasize the importance of using condoms
• Address active injection drug use
– Disclosure of HIV status to sex and needle-sharing
partners , and discuss potential barriers to disclosure.
• Note issues that will require follow-up:
– risk behaviors that require continuing counseling and
– referral and partners who should be notified by either
the patient or a health department.
Case scenario 2.
A patient with chronic, stable HIV comes to you with a new STD. What
prevention considerations should be covered in this visit?
Discussion
• New STIs suggest emerging social, emotional, or substance abuse
problems. These potential problems should be addressed in
addition to the STD.
• Ask about new partners, number of episodes of unsafe sex, and
types of unsafe sex.
• Address personal or social problems such as substance abuse or
relationships that may have resulted in the new STD; refer to social
services, if necessary
• Review personal risks associated with high-risk behavior such as
superinfection with another HIV strain and HIV/STD interactions.
Case scenario 2.
A patient with chronic, stable HIV comes to you with a new STD. What
prevention considerations should be covered in this visit?
Discussion
• Address other issues (e.g., adherence to HAART) that may be
affected by personal or social problems.
• Check viral load if nonadherence is evident or is suspected.
• Perform genital and rectal examination and screen for additional
STDs, such as syphilis, tichomoniasis (women), chlamydial infection
(for sexually active women aged 25 years and selected populations
of men and women), and gonorrhea (for selected populations of
men and women).
• Discuss the need for partner notification and referral for counseling
and testing.
• Note in the medical record that risk behavior should be addressed in
future visits and that tailored counseling may be needed for the
patient.
Case scenario 3.
A patient with chronic, stable HIV has been seen regularly in a healthcare setting. What should be included in this patient’s routine
clinical care?
Discussion
• Discussion of sexual and needle-sharing practices should be
integrated into a routine part of clinical care.
• Periodically (e.g., annually) screen for STDs. STDs to be included in
screening should be determined by the patient’s sex, history of
• high-risk behavior, and local epidemiology of selected STDs.
• Reiterate general prevention messages and patient education
regarding partner notification, high-risk behaviors associated
• with transmission, prevention of transmission, or condom use, as
deemed appropriate by the clinician