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Download Women & HIV - Honors 490 - Professor Penner
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Women & HIV Jennifer Ballard Dwan, MD Assistant Professor, OB/GYN Boston University Medical Center [email protected] Women & HIV • Introductions – How did I get here? – Clinical case • • • • History: The epidemic from past to present HIV/AIDS here and now Changing Lives Resources [email protected] Introductions • Who am I? – Currently Asst. Professor of OB/GYN at Boston Medical Center – Obstetric director, Positive HOPE – Maternal-Fetal Medicine specialist [email protected] Introductions • How did I get here? – Lots of books: • And the Band Played On – Randy Shilts • My Own Country - Abraham Verghese • Books on epidemiology and discovery of disease – Undergrad / Med School at UMich – Rotations at CDC – Residency, Fellowship, & Research [email protected] Clinical Case [email protected] Accessrx.com Clinical Case • FG presented to ER with headache and seizures. – 37yo Ugandan asylee, in US x 7 years – MRI concerning for either brain lymphoma or toxoplasmosis – Oral thrush (yeast infection) – Boyfriend 2 years, no h/o STDs – Doctors offered HIV testing: declined, “too scared” • Offered CD4 cell counts = 42 (normal > 500) [email protected] Clinical Case • What are FG’s barriers to testing? – Fear of a positive diagnosis • AIDS = Death • Poor understanding of available treatments – Relationships • Infidelity or untruthfulness in partner • Loss of partner • Community reaction – Financial risk • Concerns of cost of testing / treatment • Loss of insurance coverage [email protected] Women & HIV • • • • • Introductions History: The epidemic from past to present HIV/AIDS here and now Changing Lives Resources [email protected] UN dept of social economic affairs. Millennium Development Goals: Report 2010 [email protected] Brief History of HIV • HIV has been found in human blood from 1959 – Likely descended from single SIV virus in 1940s-50s • June 5, 1981: Initial case report of clusters of rare diseases in gay men • 1982 – Acquired Immune Deficiency Syndrome defined – 4 key risk factors: homosexuality, IV drug abuse, Haitian origin, and hemophilia A CDD FAQ: http://1.usa.gov/s03GqC [email protected] Brief History of HIV • 1983 – (HIV) virus discovered – 5th risk group added: women with AIDS + sexual partners • 1985 – First PMTCT guidelines, – first HIV test available for blood testing • 1987 – First antiretroviral drug (ZDV) approved by FDA • 1988 – WHO reports Women > Men with HIV in Africa • 1990 – Ryan White CARE Act funds community agencies for treatment / testing • 1994 – USPHS & ACTG 076 Trial recommends ZDV for pregnant women to prevent MTCT – NIH requires increases in women / minorities in HIV research http://www.kff.org/hivaids/timeline/hivtimeline.cfm [email protected] Brief History of HIV • 1995 – Peak deaths in US: 75,457 – Highly active anti-retroviral therapy (HAART) • 1997 – US HIV deaths decline by 40% • 2000 – MA is first state to give Medicaid to low-income people with HIV • 2002 – UNAIDS: Women = ½ of HIV infections worldwide • 2003 – PEPFAR: world HIV, TB, and Malaria assistance [email protected] Brief History of HIV • 2006 – CDC: Routine HIV screening for 13-64yo, annually for high risk groups • 2010 – Official US Gov’t travel & immigration ban on HIV+ people lifted – Ban lifted on federal funds for needle exchanges • 2013 – UNAIDS states new infections down 33% [email protected] [email protected] www.WHO.int/en Women & HIV • Introductions – How I got here today – Clinical case • • • • History: The epidemic from past to present HIV/AIDS here and now Changing Lives Resources [email protected] HIV/AIDS 2013 1.1M living with HIV in US - ~50,000 new infections / yr - New infections in women: - Heterosexual (84%) - IVDU (16%) - 21% decrease from 2008 2010 (9,500 women) [email protected] http://www.cdc.gov/hiv/pdf/statistics_basics_factsheet.pdf HIV/AIDS 2013 • Black / AA are 14% of the population but acquire 44% of new HIV infections [email protected] http://www.cdc.gov/hiv/library/infographi cs.html HIV/AIDS 2013 • HIV in Massachusetts – 18,459 people have been diagnosed with HIV in MA • Estimated 4,767 are HIV+ with unknown status (18%) [email protected] http://www.mass.gov/eohhs/docs/dph/aids/2013 -profiles/epidemic-glance-data.pdf HIV/AIDS 2013 • As of 2012: ~7,800 Women living with HIV in MA – 45% decrease in new HIV dx since 2002 (184 women) • Exposures: – (Presumed) Heterosexual contact = 72% – Drug use = 11% – Undetermined = 17% [email protected] http://www.mass.gov/eohhs/docs/dph/aids/2 013-profiles/epidemic-glance.pdf HIV/AIDS 2013 • Incidence higher for non-white women • Black • Hispanic • White = 1,124 / 100,000 = 557 / 100,000 = 46 / 100,000 (25x) (12x) • Proportionally more HIV+ women are minorities • Black • Hispanic • White [email protected] 45% 27% 26% 6% population 8% http://www.mass.gov/eohhs/docs/dph/aids/2 013-profiles/epidemic-glance.pdf HIV/AIDS 2013 Dec 2012: -149 / 100,000 women living with HIV in MA -23x higher prevalence in Black women -12x higher in Hispanic women -5 / 100,000 women in MA had a new HIV diagnosis (‘08-’12) [email protected] http://www.mass.gov/eohhs/docs/dph/aid s/2012-profiles/differential-impact.pdf http://www.thepromota.co.uk HIV/AIDS 2013 • Risky sex is common: – 82% women report no condom use at last sexual encounter • Monogamous relationship 69% • Other contraception 15% – 45% School-age women have had sex • 11% report 4+ sexual partners • 51% report condom use last encounter [email protected] Clinical Case [email protected] Accessrx.com Clinical Case • FG decided to get tested 1 month later (2003): HIV+ with AIDS • By 2004, still did not tell BF, but thought he was positive and seeing a doctor – Condom use “most of the time” – 2009 new sexual partner vs. same partner • HIV positive? • Partner “reluctant to use condoms” • Requests “discreet” contraception • 2010 planning pregnancy – no ART change • 2011 pregnancy Clinical Case • What are the barriers to discussing HIV+ status? – Fears of emotional abandonment • Partner • Family members / friends – Financial • Rent, other expenses • Fear of job loss – Stigma • Associated with promiscuity, drug use, MSM [email protected] [email protected] It is currently against Massachusetts law for a person’s HIV status to be revealed to a third party without permission Cfr.org [email protected] HIV Treatment / Prevention • • • • • • Education / Empowerment Condoms / Circumcision PMTCT Addiction treatment / Needle programs HAART HIV prophylaxis [email protected] HIV Treatment / Prevention • Education / Empowerment – The more people know, the less they spread HIV • Higher education level • Understanding mode of transmission – Improved social standing = More control • Financial independence • Family planning • Decreased sexual violence [email protected] HIV Treatment / Prevention • Condoms / Circumcision – Latex Condoms • decrease HIV viral exposure • Reduce STIs that increase HIV acquisition • Prevent pregnancy – Male Circumcision • Drastically reduces M F transmission • Reduces male STIs [email protected] HIV Treatment / Prevention • PMTCT – Without ART, HIV+ mothers will have HIV+ babies 25% of the time – New infections in pregnancy increase MTCT • High viral loads • Virus crosses placenta? – Breastfeeding alone carries ~12% risk of HIV [email protected] HIV Treatment / Prevention • PMTCT – Medications decrease risk • With medications only at delivery, risk is 8% • With HAART and delivery meds, risk is ~1% – No breastfeeding in US, but recommended where water quality is poor • Decreased infant mortality overall (cholera, other infections) [email protected] HIV Treatment / Prevention • Addiction treatment / Needle programs – Treatment for addiction reduces • Likelihood of needle sharing • Risky sexual behavior • Sex-for-Drugs or Sex-for-Resources – Reducing needle sharing decreases HIV, HCV and HBV sharing • HIV is more infectious with hepatitis present [email protected] HIV Treatment / Prevention • HAART (Highly Active Anti-Retroviral Tx) benefits – Individuals: • Decreases plasma viral load and infectivity • Slows progression to AIDS – Society: • Decreases community viral load • Slows rate of new cases – Generations: • Decreases PMTCT • Reduces age groups decimated due to HIV [email protected] HIV Treatment / Prevention • HIV Prophylaxis – Novel medications • Microbicides • HIV vaccine • HIV medications to HIV- persons at risk – Tenofovir PrEP – Oral medications [email protected] Clinical Case [email protected] Accessrx.com Clinical Case • Pregnancy – Prior SAB x 1, TAB x 1 – Risks: HIV/AIDS, Age, Medication exposure, HTN, Hep B, HSV – Normal labs, testing for Down syndrome – Attended 13 prenatal visits (!!) – Undetectable viral load, BC plan, delivery plan, term pregnancy …and… [email protected] Clinical Case • …Delivered emergently at community hospital – Abruption, blood exposure for baby – No medication prior to delivery – Refused medical records release – Declined “just in case” meds for baby – Came to BMC 4 days after delivery for baby medications – Late prescription filling – more time lost [email protected] Clinical Case • The aftermath: – Distraught OB/GYN, ID, and Pediatrics care givers – ? Filing of 51-A (Child abuse and neglect) – Still with non-disclosure to sexual partner – Baby girl remains HIV negative to date (whew!) [email protected] Social Support Disclosure Housing Discrimination Stigma Denial Privacy [email protected] Fea r Resources • HIV / AIDS Action of MA – http://AAC.org • HIV Drug Assistance Program (HDAP) – http://www.crine.org/hiv_drug_assistance_pro gram.html • MA Resources.org – http://www.massresources.org/hiv.html • National HIV Consultation Center: – (800)933-3413 Reading & Resources • Kaiser Foundation HIV timeline – http://bit.ly/tAvW2Y • 2011 US HIV statistics report (CDC): – http://1.usa.gov/1fCTGVS • 2013 MA data fact sheet: – http://1.usa.gov/1fCTkPg • ACTG 076 Trial of PMTC: – http://bit.ly/ACTG076 • AIDSInfo.gov – up to date treatment / testing info [email protected] THANK YOU [email protected]
