Care of Women with HIV Living in Limited-Resource Settings
Prevention
Jean R. Anderson, MD Director Johns Hopkins HIV Women’s Health Program
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Resources
A Guide to the Clinical Care of Women With HIV: 2001 First Edition
To request the guide, send e-mail to ask@hrsa.gov
Care of Women With HIV Living in LimitedResource Settings tutorial series
For more information about the HIV tutorial series, send e-mail to hiv-aids@jhpiego.net.
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Learning Objectives
Why prevention is important Progress made in HIV prevention Modes of HIV transmission Most effective interventions for reducing transmission
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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
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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 0 20 87% 52% 87% 60% 46% 45% 63% 36% 21% 52% 50% 40 60 Percentage 80 100
Source: UNICEF 1999
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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 20 40 60 Percentage 80 87% 87% HIV prevalence rate in women attending antenatal care clinics in major urban areas (at time of survey) 100
Source: UNICEF 1999.
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Trends in HIV Prevalence in Selected Populations
Kampala, Uganda, < 20 year old antenatal clients1
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Thailand, 21 year old military conscripts2
Dakar, Senegal, all ages antenatal clients1
HIV prevalence (%)
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
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Percentage Sexually Experienced by Current Age (15–24 years old) in 1989 and 1995 — Uganda
100
% Sexually Experienced
75
50
Women 1989 Men 1989 Women 1995 Men 1995
25
0 15 16 17 18 19 20 Age 21 22 23 24
Source: UNAIDS 2001.
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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 Age 20-24 Age 25-29
% Visiting Sex Workers in 12 months
1990 1993 1997
Sources: Sittitrai et al, Thongthai et al, Chamratrithirong et al. Need dates
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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%
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Factors Affecting Sexual Transmission of HIV
Infectiousness Late Clinical Stage Primary HIV Infection Antiretroviral Therapy Genital Tract Infection Cervical Ectopy Circumcision Method of Contraception Barrier Hormonal Spermicidal IUD Menstruation Pregnancy
Source: Royce et al 1997.
Susceptibility N/A N/A ?
?
? ? ?
?
?
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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
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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
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Modes of Transmission
continued
HIV is NOT transmitted by:
Insect bites Kissing Hugging Touching toilet seats Sharing eating utensils
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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
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HIV Prevention – What Works?
continued
Antitretroviral (ARV) and breastfeeding interventions to prevent mother-to-child transmission (MTCT) Safe transfusion practices
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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
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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
STIs: woman or partner
History Signs or symptoms
Mobile population
Refugee Husband in military or long-distance truck driver
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
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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
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Percentage of Sexually Active Men and Women Who Have Ever Used a Condom, Urban Uganda, 1989 and 1995
70
% Ever-Used Condoms
60 50 40 30 20 10 0 15-19 20-24 25-39 Age Groups 40-49 All
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Women 1989 Men 1989 Women 1995 Men 1995
Source: UNAIDS 2001.
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
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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
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Female Condom versus Male Condom
Male Condom
Made from latex; some also from polyurethane Fits on the penis Lubricant: Can include spermicide Should be water-based only for latex Located on the outside 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 Condom must be put on an erect penis Must be removed immediately after ejaculation Should not be reused
Female Condom
Made from polyurethane Loosely lines the vagina Lubricant: Can include spermicide Can be water-based or oil-based Located on the inside of condom 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
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 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
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Protection Against HIV Offered by Other Contraceptive Methods continued
Diaphragm
No significant protection against HIV transmission Limited STI protection
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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.
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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
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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
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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
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Rates of STIs Among Pregnant Women in Dakar, Senegal, 1991–1996
35 30.1 30
STD Prevalence (%)
1991 (n = 511) 1996 (n = 540) 18.1 11.9 6.7 2 0.9
Trichomonas vaginalis Chlamydia trachomatis Neisseria gonorrhoeae Syphilis
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25 20 15 10 5 0
7.5 4.4
Source: UNAIDS 2001.
Comparison of Increase in Condom Use with Decline in Reported Male STIs on a National Scale, Thailand, 1989–1994
200 65 Male STDS Condom Non-use
Reported Male STDs (in 1000s)
180 160 140 120 100 80 60 40 20 0 1989 1990 1991 1992 1993 1994
45 35 25 15 5 -5
% of Sex Acts Not Protected by Condoms
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Source: UNAIDS 2001.
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
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MTCT Transmission with Short Course Oral ARV Regimens
Site No Breastfeeding Thailand Breastfeeding Côte d’Ivoire ZDV: 36 weeks, labor 37% (3 months) ZDV: 36 weeks, labor 50% Regimen MTCT Reduction
ZDV: 36 weeks, labor, postpartum (mother)
Uganda, Tanzania, South Africa ZDV/3TC: 36 weeks, labor, postpartum (mother & newborn) ZDV/3TC: labor, postpartum (mother & newborn) Uganda NVP (single dose): labor, postpartum (newborn)
38% (6 months)
52% (6 weeks) 38% (6 weeks) 47% (4 months)
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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
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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
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Prevention — TransfusionRelated continued
Select donors carefully: Family replacement and paid or professional donors higher risk Screen blood supply
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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
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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
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Prevention Lessons Learned
continued
Socioeconomic interventions to reduce vulnerability are needed
Education of girls Protection of human rights Reduction of stigma
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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
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HIV Prevention — Future Research
Microbicides Postexposure prophylaxis Vaccines
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References
1. 2. 3. 4. 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.
5.
6.
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References continued
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.
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7.
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.