Sexual Risk Reduction with HIV Positive Adults
SANEESE STEPHEN, RPA-C, MPAS CENTER FOR H.O.P.E. KINGS COUNTY HOSPITAL
Why are we so concerned
About SEXUAL BEHAVIOR?
HIV positive persons are living longer…and guess what?
They are having SEX !!!!!!!
31 y/o F dx HIV+ 2000 Oct 2000 Jan 2000 Start D4T/3TC/Nelfinavir Feb 2001 Mar 2001 May 2001 May 2001
Viral Load 371,862 1,267 <400 3,220
Cd4 (%) 11 (1) 289 (10) 298 (8) 188 (9)
Geno / Pheno Type Ord 7,276
JUNE 2001 START TRIZIVIR/INDINAVIR/NORVIR 800-100
JULY ‘01-MARCH ‘02 VL = 153-441 APRIL 2002 VIRAL LOAD < 50, T-CELL= 209 (10)
AUGUST 2002 VL= 791, TCELL = 242 (12) SEPTEMBER 2002 : 4-5 WKS PREGNANT, VL=682
DEC 2002: VL=648
FEB 2003: VL=478
Resistant HIV
Johnson VA, et al. J Infectious Disease. 2001;183:1688-1693 Infant with proviral DNA with evidence of RT mutations (M41L, L74V, and T215Y) and 3 PR substitutions (K20R, M36I and V82A) Mother’s proviral DNA had same substitutions Confirmation for Vertical transmission of MDR HIV
High Risk Sex
Procreation
Behavioral Alcohol/Substance Abuse
Intimacy
Guilt/Empathy Unprepared/Uneducated
HIV Epidemic in US/NYS
1n 1999, 84% of residents diagnosed with AIDS were people of color (minorities) Of Total AIDS cases in US 56.6% are Minorities 78% Women 82% Children NYS accounts for >25% of all reported AIDS cases among women in the US of which 31.8% due to heterosexual contact As of 6/2000, 19% on nation’s total AIDS cases were in NYS (140,000)
HIV Epidemic in US
Through 2001 – 816K AIDS cases (CDC)
White
MSM IDU 70% 13%
Black
30% 39%
Hispanic
37% 38%
MSM/IDU
Hetero Other
8%
7% 3%
6%
23% 2%
6%
17% 2%
Sexual Transmission
Most common route of HIV transmission in the world (75%) Probability of Transmission 1. Infectiousness of Index case 2. Mode of Sexual Contact 3. Susceptibility of Person Exposed
HIV Mucosal Transmission
Cell free virus or cell-associated ????
Seminal plasma
Endocervical swab
specimens Cervicovaginal lavage samples
HIV Transmission
Method
of Sexual Intercourse Viral Load in Blood Advanced Stage of Disease Primary Infection HIV Clade Initial Sexual Contacts
HIV Transmission
Foreskin
Cervical
ectopy Menstruation Immune activation Genital Ulcers Genital tract trauma
Transmission Probability
Infectivity per Contact
Female Male Male Female Male Male
Needle Stick Needle Sharing Mother Infant Mother Infant (AZT)
0.0002 – 0.008 0.0008 – 0.009 0.0009 – 0.085
0.002 – 0.0095 0.009 0.2 – 0.3 0.08 – 0.10
M. Cohen and J. Enron, Sexual HIV Transmission and Its Prevention, Jan 2002 (Medscape)
Transmission Probability
Concentration of HIV in Plasma is a Important Determinant
Viral Load <3,500 >50,000 Risk 1/10,000 5.1/1000
Uganda
Gray et al. Lancet 2001,357:1149-1153
High Risk Sexual Behavior
Younger Age Low Education Level History of STD Drug or Alcohol Use During Sex Depression Engage in Oral or Anal Sex Partner did not have AIDS
Sexual Behavior Risk Assessment – Stephen S (2000)
HIV positive persons attending SUNY Brooklyn (N=150) Mean Age = 38.4 years SD = 8.5 Women = 89 (59.3%) Men = 61 (40.7%) BK (72%), HP (14.7%), MD (6.0%), WT (5.3%), Single (64%), Married (16%), Other (18%)
Sexual Behavior Risk Assessment – Stephen S (2000)
Sexual Partner in Past 3 Months Men (n=61): 45(73.8%) Women(n=89): 60(67.4%) Main Partner: Men 33(54%) Women 45(50%) NonMain Partner: Men 12(19.6%) Women 15(16.9%)
Sexual Behavior Risk Assessment – Stephen S (2000)
High Risk Sexual Behavior (HRSB) • 31.9% of patients practice HRSB with main partner during vaginal sex in past 3 months
• 31.8% of patients practice HRSB with nonmain partners during vaginal sex in past 3 months
Sexual Behavior Risk Assessment – Stephen S (2000)
Disclosure to sexual partners
51% of men and 60% of women always disclose HIV+ status 24% of men and 21% of women never disclose HIV+ status
High Risk Sexual Behavior
Margolis et al. AIDS 2001 Survey of 250 HIV infected gay men in SF 37% reported recent unprotected anal sex with potentially uninfected partner 23.3% of men reported that health care provider had never spoken to them about safer sex
High Risk Sexual Behavior
Elford et al 1999 more than 33% of gay men are less concerned about HIV infection with advances in treatment Remien et al 1999 HIV + gay men more likely to have unprotected sex since they believe that they are longer infectious with HAART
High Risk Sexual Behavior
Van de Ven P et al (1999) Association with unprotected anal intercourse and optimism with new HIV Rx Miller et al (2000) No significant increase in HRSB with initiation of HAART Wilson et al (2001) ART may be associated with increased risk behavior in HIV+ minority women
Resistant HIV
Little SJ, et al Antiviral Therapy 2001. Abs 25 8th Conf. on Retro & Opport Infect (2/01)
389 tx-naïve subjects from 9 NA cities 16. 5% of subjects with >10 fold reduced susceptibility to one or more ARVdrugs (4.6% in previous report, p=0.002) Multi-drug resistance (two or more classes) increased from 1 to 6% (p=0.01)
Resistant HIV
UK Collaborative Group BMJ. 2001;332:1087-1088 14% of 69 newly infected patients had one or more key HIV-1 mutations Briones C (Madrid, Spain) J Acquired ID Syndrome.2001;26:145-150 26.7% of 30 newly infected patients had genotypes with reduced susceptibility
Feb ’02 – 37 yo BM, bisexual, recently tested HIV+, h/o oral thrush. Male partner recently died of HIV illness.. VL= 15, 876 T cell= 21 (2%)
March ’02 – Start Trizivirr
April ’02 – Treated for Rectal Herpes. VL= <400, T cell = 51 (4%) June ’02 – Treated with Cryotherapy for HPV VL= 684, T cell= 90 (5%), misses 2-3 doses/month July ’02 – VL 6, 508 and T cell = 79 (4%)
Aug ’02 – Genotype Collected
RT: M41L, M184V, L210W, T215Y (Reduced susceptibility to all NRTI) PI: L10L/I, M46L, L63P, L90M (Reduced susceptibility to IDV, NFV, RIT, SQV)
Sep ’02 – Start Lopinavir,Viread, Videx, Efavirenz, and Combivir (13 pills daily)
Feb
2003 –
VL 61 Tcell= 241 (14)
Requests
Sildenafil (Viagra) ….
Evaluation for
Impotence Sildenafil always given with CONDOMS
HIV Superinfection
XIV Int. AIDS Conf. Barcelona, Spain
• Dr. Bruce Walker: studies with STI • Control of low level viremia with increased •
CD8 T cell CTL responses Superinfection by second Clade B virus differing by 12% caused loss of control
Postexposure Prophylaxis
CDC and Expert panel recommends PEP 28 day course of HAART regimen Needle Stick Exposure High Risk Sex Rape
Cardo et al NEJM 1997;337:1485-1490 CDC Guidelines for STD Treatment MMWR 1998
Prevention Initiative
February 2001 – CDC launches S.A.F.E.
(Serostatus Approach to Fighting HIV Epidemic)
1.
2.
3. 4.
5.
Encourage voluntary testing Improve access to to healthcare if HIV + Provide appropriate therapy Emphasis on Adherence Promote safer sexual behavior
Sexual History
Initial History:
HIV risk factor Sexual Partners History of abuse, or rape Drug/EtOH use during sexual activities History of GC/Chl, Syphilis, HPV, HSV Condom Use history, last 3 months, last sexual encounter
34 y/o BF dx HIV+ in 1999
Baseline VL =16, 135 Tcell=702 (32%)
3 HIV- children HIV+ Partner (on treatment)
June 2002, 9 wks Pregnant
• History of 5 VTOP
• Further discussion reveals EtOH abuse
• Partner is inconsistent with condom use • Social Work, Health Educator, Nursing
• Admitted to Alcohol Abuse Treatment
Program, continues to attend meetings
Sexual Education/Discussion
Avoid medical
jargon Provider comfortable about discussions will facilitate Patient discussion Medical /Psychological history if patient is not sexually active Contraception, and Family Planning Condoms are covered by Medicaid
Talking About Safer Sex
Prevention First
Develop Trust Communicate about Sexuality Communicate the
Risks Identify Related Factors ON GOING DISCUSSIONS
M. Cohen and J. Enron, Sexual HIV Transmission and Its Prevention, Jan 2002 (Medscape)
28 y/o HP male dx 2000
Baseline
VL 26,948 T cell = 248 Denies current sexual activity Started on HAART VL <50, Tcell > 600 Returns to work and has girlfriend Interested in having child
HIV + male, HIV - Female
Educate Client
Explore Options
Girlfriend presents
HIV
to clinic
Testing
Behavior Changes
Sexual Abstinence Sexual Monogamy Proper and Consistent Condom Use Early Treatment of STD Adherence to ARV for Maximal Suppression of HIV Viral Load
43 y/o BM dx HIV + 1996
• • • • • •
Highly Experienced to HAART History of NonAdherence Poor toleration of Meds Highly Resistant to 3 Classes of ARV VL >500K, Tcell 20-80 Sexually active with multiple women
High Risk for Transmission
• Adherent to Clinic appts • Refuses ARV • Psychiatry evaluation • ONGOING discussion on Condom use • MDI Case Conference
Power of Condoms
HIV
acquisition reduced by 50-100% in men who use condoms in 10 cohort studies De Vincenzi et al. NEJM 1994 123 Discordant couples in Europe Deschamps et. Ann IM 1996 1 of 42 infections with consistent condom use 7-14% infection with inconsistent use
Smoking Cessation
Provider initiated
behavioral change method is affective for smoking cessation
Pieterse
M, et al. Preventive Medicine 32(2):182-90. 2001 February Easton A, et al. Women and Health 32(4):77-91, 2001
Behavioral Intervention
Shain et al (1999) Randomized trial of 424 Mexican women and 193 African American women Intervention of three small group sessions of 3-4 hour sessions Retention of 89% of sample at end of 12 months Intervention group had significantly lower rates of GC, Chlamydia at 6 mos (p=0.05), second 6 mos (p=0.008) and over entire 12 month study period (p=0.004)
Behavioral Intervention
Kalichman et al (2001) Randomized trial of 232 men and 99 women with HIV from ID clinics in Georgia 5 session group intervention and followed for six months post intervention Intervention group at 6 months had significantly lower reported Unprotected vaginal/anal intercourse (P<.01) Demonstrated HIV risk-transmission reduction
Partner Notification
NYS Regulation on June 1, 2000 PN to get newly exposed/infected patients into medical care De crease spread of HIV Data for planning and funding of care Mandatory for spouses Options for Self-Notification or Deferral
Disclosure of HIV Status
Benefits of early diagnosis and treatment Potential to limit the spread of HIV through education and counseling Consequence of abuse, separation with partner who may be sole provider of financial and emotional support Stigma with HIV diagnosis is still present
Discussing Disclosure of HIV
Stein M. and Samet J. AIDS Patient Care and STD. 1999;13:265-7 Express empathy for the difficulty of choosing disclosure Have Patient state Pros and Cons Avoid argument to convince by force or moral argument Describe successful disclosures you, as a clinician have facilitated