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Incorporating HIV Prevention into the Medical Care of Persons Living with HIV

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Incorporating HIV Prevention into the Medical Care of Persons ... Baths, parks. Internet. Anonymous partners. Ciesielski 2003, Katz 2002. The STD Cofactor ... – PowerPoint PPT presentation

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Title: Incorporating HIV Prevention into the Medical Care of Persons Living with HIV


1
Incorporating HIV Prevention into the Medical
Care of Persons Living with HIV Introduction and
Rationale
Ask Screen Intervene
Developed by The National Network of STD/HIV
Prevention Training Centers, in conjunction with
the AIDS Education Training Centers
2
Learning ObjectiveIntroduction to AHP and PWP
  • Describe rationale for implementing consensus
    recommendations

3
AHP Strategies
  • Four priority strategies
  • Make voluntary HIV testing a routine part of
    medical care
  • Expand HIV testing outside medical settings
  • Prevent new infections by working with persons
    diagnosed with HIV and their partners
  • Further decrease perinatal HIV transmission

MMWR April 18, 2003/52(15)329-332
4
Prevention with Positives (PWP)The
Recommendations
  • Developed by CDC, HRSA, NIH, HIVMA, with
    evidence-based approach
  • Apply to medical care of all HIV-infected
    adolescents and adults
  • Intended for those providing medical care to
    HIV-positive persons

MMWR, July 18, 2003
5
What are the Recommendations?
PwP
  • Medical providers can substantially affect HIV
    transmission when they
  • screen for risk behaviors
  • identify and treat other STDs
  • communicate prevention messages
  • discuss sexual and drug-use behavior
  • positively reinforce changes to safer behavior
  • refer patients for services (substance abuse
    treatment)
  • facilitate partner notification, counseling, and
    testing

MMWR, July 18, 2003
6
Why PWP?
  • Most people who are aware of their HIV infection
    are practicing safer sex
  • Every HIV transmission event involves a person
    already HIV infected (IOM)
  • Those living with HIV are fewer in number and
    easier to define that those at risk
  • Most HIV persons have contact with healthcare
    system
  • Better prevention services to HIV will improve
    their health outcomes

7
Driving Concerns Behind the New InitiativeAre
HIV Prevention Efforts Working?
  • Prevention efforts to date have emphasized
    working with HIV-negative persons to remain
    uninfected
  • CDC estimates
  • 40,000 new HIV infections occur in the U.S. each
    year
  • Essentially no change in this number over the
    last decade
  • One quarter of HIV-infected Americans do not know
    they are infected
  • Recent increases in STDs suggest increases in
    unsafe sexual behaviors
  • STDs increase HIV transmission risk by 2-5 fold

8
(No Transcript)
9
Estimated Number of New HIV Infections in US
Annually
10
Awareness of Serostatus Among People with HIV
and Estimates of Transmission in US
11
Proportion on Men Reporting Anal Sex Before and
After Knowing HIV-Positive Status
Percent Reporting Risk Behavior
Colfax et al, AIDS 2002
12
Why is it Important NOW?
  • Emerging trends among the HIV-infected
  • Increases in unsafe sex
  • Increases in syphilis, gonorrhea
  • Transmission of drug-resistant virus
  • STDs increase amount of HIV shed at genital
    mucosa (cervix, urethra, rectum)
  • Directly increases risk of transmitting HIV

Rietmeijer, Chen, Collis, Novak, Tang, Weinstock,
Blackard, Jost, Erbelding
13
Emerging Trends Among HIV-Infected
Men-Who-Have-Sex-With-Men (MSMs)
14
MSM Prevalence Monitoring Project Test
positivity for gonorrhea and chlamydia among men
who have sex with men, by HIV status, STD
clinics, US, 2003
15
Gonococcal Isolate Surveillance Project Percent
of Neisseria gonorrhoeae isolates with resistance
to ciprofloxacin by sexual behavior, 20012003
16
Primary and Secondary Syphilis Cases, by Sex,
1997-2002 Some Large US Cities
New York City
Los Angeles
400
400
200
200
0
0
1998
1999
2000
2001
1998
1999
2000
2001
1997
2002
1997
2002
San Francisco
Chicago
400
400
200
200
0
0
1998
1999
2000
2001
1998
1999
2000
2001
1997
2002
1997
2002
17
HIV Status Among Men Who Have Sex With Men
Primary Secondary Syphilis Cases -
California,20012003
8/2004 Provisional Data - CA DHS STD Control
Branch
18
Why is this Occurring?
  • Improved HIV therapy, well-being, and survival
  • Prevention fatigue
  • Increased use of erectile dysfunction drugs,
    methamphetamine, poppers
  • Old new ways to meet partners
  • Baths, parks
  • Internet
  • Anonymous partners

Ciesielski 2003, Katz 2002
19
The STD CofactorMechanisms by Which STDs
Increase HIV Spread
  • Transmission
  • Inflammatory conditions increase viral load in
    secretions
  • Virus can be cultured from genital ulcers
  • Susceptibility
  • Breaks in epithelial barrier allow viral access
  • Inflammation increases number and/or receptivity
    of target cells
  • Enhancement of viral survival (increased pH
    and/or lack of H2O2 in vagina may lead to
    prolonged viral survival)

20
Urethritis Increases HIV in Semen
Median concentration of HIV-1 RNA in semen among
135 HIV-infected men in Malawi w/ and w/o
urethritis
Treatment
x 104 copies/ml
Cohen M et al. Lancet 1997 349 1868-1873
21
Effect of STD on HIV SusceptibilitySummary
Estimates (ORs) from Cohort Studies
Rottingen et al STD 2001
22
The Impact of STDs on Sexual Transmission of HIV
  • Similar behaviors transmit HIV and STDS
  • Vaginal and anal intercourse
  • STDs increase susceptibility to and
    infectiousness of HIV infection
  • Risk of HIV transmission is 2 to 5 times higher
    in the presence of other STDs
  • SO Risk assessment and STD screening is an
    effective intervention for reducing HIV
    transmission

Wasserheit Fleming
23
Prevention with PositivesWhat Providers Can Do
  • ASK
  • Assess for sexual and IDU risk behaviors
  • SCREEN
  • Identify and treat STDs
  • Assess for pregnancy
  • INTERVENE
  • Provide prevention messages behavioral
    risk-reduction interventions
  • Refer for Partner Counseling and Referral Services

24
Additional Information on AHP
  • www.cdc.gov/hiv/partners/ahp.htm
  • CDC. Advancing HIV prevention New strategies
    for a changing epidemic. MMWR 200352329-332
  • www.stdhivtraining.org
  • www.paetc.edu

25
Acknowledgments
  • HIV Prevention in Care Curriculum Working Group
    (NNPTC-AETC)
  • CDC Program Liaisons
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