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 1 vaginal lubricant
Protection Against HIV Offered by Other Contraceptive Methods
continued
Diaphragm
No significant protection against HIV transmission Limited STI protection
2
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. 3
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
4
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
5
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
6
Rates of STIs Among Pregnant Women in Dakar, Senegal, 1991–1996
35 30 30.1
STD Prevalence (%)
1991 (n = 511) 1996 (n = 540) 18.1 11.9 6.7 2 0.9
Trichomonas vaginalis Chlamydia trachomatis Neisseria gonorrhoeae Syphilis
7
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
Reported Male STDs (in 1000s)
180 160 140 120 100 80 60 40 20 0 1991 1992 1993 1994 Male STDS Condom Non-use
45 35 25 15 5 -5
1989 1990 Source: UNAIDS 2001.
8
% of Sex Acts Not Protected by Condoms
55
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 Safely dispose of syringes after use 9
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
10
MTCT Transmission with Short Course Oral ARV Regimens MTCT
Site No Breastfeeding
Thailand Breastfeeding ZDV: 36 weeks, labor 50%
Regimen
Reduction
Côte d’Ivoire
ZDV: 36 weeks, labor
ZDV: 36 weeks, labor, postpartum (mother)
37% (3 months)
38% (6 months)
Uganda, Tanzania, South Africa
ZDV/3TC: 36 weeks, labor, postpartum (mother & newborn) ZDV/3TC: labor, postpartum (mother & newborn)
52% (6 weeks) 38% (6 weeks)
47% (4 months)
Uganda
NVP (single dose): labor, postpartum (newborn)
11
Preventing MTCT in Low-Resource 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 Photo by: Hugh Rigby, Kenya, 1982 Seek prompt treatment of mastitis or breast abscess and oral thrush in newborns 12 Breastfeed exclusively for up to 6 months
Prevention — Transfusion-Related
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
13
Prevention — Transfusion-Related
continued
Select donors carefully: Family replacement and paid or professional donors higher risk Screen blood supply
14
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
15
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
16
Prevention Lessons Learned
continued
Socioeconomic interventions to reduce vulnerability are needed
Education of girls Protection of human rights Reduction of stigma
17
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
18
HIV Prevention — Future Research
Microbicides Postexposure prophylaxis Vaccines
19
References
1. 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. 20
2.
3.
4.
5.
6.
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. 21
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), Sep-Oct 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, 22 HRSA, HAB. Washington, D.C. 2001.