View
38
Download
1
Category
Preview:
DESCRIPTION
HIV/AIDS in INDIAN COUNTRY: Do we have a problem?. Dee Ann DeRoin, MD, MPH National Native HIV/AIDS Awareness Day March 20, 2008. WHY ARE WE HERE?. To discuss the enormous risk for an HIV outbreak in one or more Indian communities - PowerPoint PPT Presentation
Citation preview
HIV/AIDS in INDIAN COUNTRY:Do we have a problem?
Dee Ann DeRoin, MD, MPH
National Native HIV/AIDS Awareness Day
March 20, 2008
WHY ARE WE HERE?
To discuss the enormous risk for an HIV outbreak in one or more Indian communities
To underscore the new CDC recommendations for routine screening
Revised Recommendations for HIV Screening in Health-Care Settings
in the U.S.
September, 2006
CDC Recommendation for HIV Screening
Opt-out HIV screening and HIV diagnostic testing should be a part
of routine clinical care in all
healthcare settings.
September 22, 2006
This information is based on: Centers for Disease Control and Prevention (CDC). (2006, September 22). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Information take from: http://www.cdc.gov/hiv/topics/testing/healthcare
Individuals in the U.S. between the ages of 13 and 64 Patients receiving care for tuberculosis (TB) Patients in care for other sexually transmitted
diseases (STDs) Women who are considering conception and
pregnancy Women who are pregnant Women in delivery who have undocumented HIV
status at the onset of labor Infants born to mothers with undocumented HIV
status.
The CDC recommends that HIV screening be a routine part of health care for all:
A QUICK HIV REVIEW
HIV Transmission
Contact with infected body fluids (blood, semen, vaginal fluid, breast milk)
Unprotected sexSharing needlesMother to fetus
Time Line of HIV Infection
Acute Infection
Asymptomatic HIV Infection
Symptomatic HIV Infection AIDS
10-15 Years
Positive Ab Test result (6 months)
3-5 Years ? Years
Pantaleo et al, NEJM, 1993
Weeks
CD
4 T
Cel
ls/m
m3
Plasm
a Virem
ia Titer
0 3 6 2 111 109 12
100
200
300
400
500
600
700
800
900
1000
1100
1100
Years3 4 5 6 7 8 9
0
1:2
1:4
1:8
1:16
1:32
1:64
1:128
1:256
1:512
Primary Infection
• Possible acute HIV syndrome • Wide dissemination of virus• Seeding of lymphoid organs
Clinical Latency
Constitutional symptoms
Opportunistic disease
Death
Typical Course of Untreated HIV Infection
Signs of Acute Infection
Fever (can be HIGH)
Lymphadenopathy
Rash (upper body, scattered oval
macules)
Ulcers: oral, pharyngeal, esophageal,
genital
ThrushSource: http://hivinsite.ucsf.edu
Symptoms
Flu-like symptoms Malaise, fatigue, myalgias, arthralgias Sore throat, mouth (no rhinorrhea) GI symptoms: abdominal pain, diarrhea Meningeal symptoms: head ache,
photophobia, stiff neck Dehydration symptoms
Source: http://hivinsite.ucsf.edu
Routine Lab Abnormalities
WBC is LOWLymphocytopeniaThrombocytopenia (100K)Mild transaminitis
Source: http://hivinsite.ucsf.edu
Diagnosis
Symptoms: 3-6 weeks after exposureAntibody seroconversion
1 to 10 weeks after onset of sx
HIV-1 RNA tests (PCR, bDNA) Positive 1 - 2 weeks before antibody Risk of false positives - only use if high pre-test
probability
Source: http://hivinsite.ucsf.edu
BASIC TENETS OF DENTAL CARE IN THE HIV/AIDS PATIENT
Oral GuidelinesThe guidelines
for good oral health care are the same for HIV positive people as they are for all dental patients
Guidelines for Infection Control in Dental Health-Care Settings
Source: CDC, MMWR, December 19, 2003:52(RR-17).Date: 12/19/2003
http://www.cdc.gov/oralhealth/infectioncontrol/ guidelines/index.htm
Oral Manifestations of HIV Infection Oral manifestations may be among
the first signs of HIV infection and thus may lead to testing and diagnosis of HIV infection.
Oral conditions may develop as immunosuppression progresses, causing signs and symptoms that require management.
Treatment Planning For The HIV+ Patient Follows The Same
Guidelines As For Non-HIV+
Relieve pain Restore function Prevent further disease Consider esthetic
results
General Treatment Planning
Modifications of care for the HIV patient are similar to those of any medically compromised person.As an example, diabetics require special consideration
because of their impaired response to bacterial infections as well as delayed healing
General Treatment Planning Strong emphasis must be placed on prevention
Each patient is different and each treatment plan must be prioritized according to that patients health needs.Deviation from the
customary treatment sequence may be indicated
Early Stage
Patients with HIV who have a CD4 count above 200 are defined as being in the early stages of the disease.
These patients should be treated the same as HIV negative patients.
Late Stage
When CD4 counts fall below 200, patients are considered to have progressed to the later stages of the disease.
Most of these patients are still easily treated in the GP office, but occasionally require antibiotic prophylaxis for invasive procedures.
Antibiotic Prophylaxis
Indicated when:Neutrophils: <500 cells/mm3
According to AHA guidelines if patient has heart/valvular problems
Need for antibiotic prophylaxis is not based on CD4 count
Indicated when:Neutrophils: <500 cells/mm3
According to AHA guidelines if patient has heart/valvular problems
Need for antibiotic prophylaxis is not based on CD4 count
Antibiotic Prophylaxis
Patients with indwelling catheters such as a Hickman catheter may require antibiotic prophylaxis prior to dental care. Medical consultation may be warranted.
Renal dialysis patients with shunts for hemodialysis require antibiotic prophylaxis prior to invasive dental care.
Patients with indwelling catheters such as a Hickman catheter may require antibiotic prophylaxis prior to dental care. Medical consultation may be warranted.
Renal dialysis patients with shunts for hemodialysis require antibiotic prophylaxis prior to invasive dental care.
Considerations in the Use of Antibiotics Preferred use of narrow spectrum antibiotics (e.g.,
Metronidazole) to minimize development of antibiotic resistance
Possibility of presence of antibiotic resistant strains Culture and antibiotic sensitivity may be indicated
Use of antibiotics may lead to overgrowth of Candida albicans Antifungal treatment may be indicated in conjunction
with systemic antibiotics Local delivery antibiotics may be useful but have
not been evaluated
Factors that Predispose to Oral Lesions
CD4+ counts < 200cells/mm3
Viral load > 3000copies/mm3
Xerostomia Poor oral hygiene Smoking
HIV/AIDS IN INDIAN COUNTRY:the Issues
Statistics Health Care Access Risk Factors Testing Barriers Treatment Availability Community Attitudes Resources
Epidemiology of HIV in US
>462,000 people living with HIV/AIDS in 2004
17% ^ prevalence from 2001 to 2004
Main risk: Sexual contact for both men and womenWomen: 71% heterosexual; 27% IDU
Disproportionate impact: African Americans & Hispanics
Campsmith M, et al. XVI IAC Toronto, Canada, Aug. 13-18, 2006; Abst. MOPE0551
‡
HIV 2006 USA
There are currently an estimated 40,000 new HIV infections per year in the United States.
More than half of new HIV infections now occur in persons under 25 years old.
NEW U.S. HIV/AIDS DIAGNOSES, 2005
MALES 28,037 = 74%
FEMALES 9,893 = 26%
TOTAL 38,096
CDC, HIV/AIDS Surveillance Report, vol. 17
HIV/AIDS Diagnoses among Adults and Adolescents,
by Transmission Category — 33 States, 2001–2004
MSM61%
IDU16%
Heterosexual17%
MSM/IDU 5%
Other 1%
Males(n ≈ 112,000)
Females(n ≈ 45,000)
Heterosexual76%
IDU21%
Other 3%
MMWR, Nov 18, 2005
AI/AN MALE HIV INFECTION SOURCE
METHOD %
MSM 61
IDU 15
MSM/IDU 11
HETEROSEXUAL 12
OTHER 1
AI/AN FEMALE HIV INFECTION SOURCE
METHOD %
HETEROSEXUAL 68
IDU 29
OTHER 2
INFECTION RATES BY RACE 2003 2005
Race/Ethnicity Rate/100,000 AI/AN 10.4 10.6AfricanAmerican 75.2 72.8Hispanic 26.8 28.5White 7.2 9.0Asian/PI 4.8 7.6
Native infection rates have been higher than rates for whites since 1995. (CDC, HIV SR, v. 17)
US Native Population 2000
AI/AN only 2.4 million 1%
AI/AN and other 4.3 million 1.5%
US total: 281million
Native Population in Kansas
AI/AN Kansas Total
1990 Census 21,965 2,477,574
2000 Census 47,363 2,688,418
24,936-AI/AN only
22,427-AI/AN multi
AIDS in INDIAN COUNTRY as of 2005
3,717 cases since early 1980’s 1,657 deaths 2,060 living with AIDS 198 new cases diagnosed in 2005
CDC, HIV/AIDS SR, vol. 17
NEW DIAGNOSES, 2000-2003
New cases diagnosed among AI/AN from 2000-2003:
Males 505 = 71%
Females 210 = 29%
12.132216.420017.211FemaleMale 87.9233983.6
1,01 782.853
%N%N%N
Cumulative AIDS Cases
PrevalentAIDSCases
Incident AIDS Cases
Kansas AIDS Cases
as of 6/30/2006
Gender
AIDS Cases by Age 6/30/2006
1.5390.563.5465 +
4.01043.2375.2655 TO 64
12.933514.516921.72545 TO 54
35.792836.943134.84035 TO 44
39.7103037.243528.73325 TO 34
5.51447.1836.1715 TO 24
0.130.11..13 TO 14 <13 0.5130.56..
%N%N%N
Cumulative AIDS Cases
Prevalent AIDS
Cases Newly Reported
AIDS CasesAge in Years
Race/Ethnicity N % N % N % % Total Pop
Hispanic 13 20.3 158 13.0 238 8.9 8.1
American-Indian Non-Hispanic
. . 11 0.9 24 0.9 0.1
Asian/Pacific Islander Non-Hispanic
. . 5 0.4 10 0.4 2.2
Black Non-Hispanic 20 31.3 282 23.2 501 18.8 5.9
White Non-Hispanic 31 48.4 744 61.1 1866 70.1 81.9
Multi-Race Non-Hispanic . . 16 21 21 0.8 1.6
Unknown Non-Hispanic . . 1 1 1 0.0 .
Incident AIDS Cases
Prevalent AIDS Cases
Cumulative AIDS Cases
Kansas AIDS Cases through
June 30, 2006
HEALTH CARE for INDIANS in KS
ITUIndian Health ServiceTribalUrban
KS INDIAN HEALTH SERVICE(IHS)
Haskell Health Center IHS White Cloud Health Station
(Ioway Reservation)
KANSAS RESERVATIONS
FEDERAL FUNDING DISPARITIES
Eligibility for IHS Care
Care available at IHS facility:Enrolled member of federally-recognized tribe
Care beyond local facility:Live within Contract Health Service (CHS) boundariesDon’t get sick in June!
HIV RISK FACTORS for NATIVES
Lack of knowledge of HIV/STI’s High STD/STI rates High rates of substance abuse High rates of emotional problems Low SES
SUBSTANCE ABUSEHighest rate of illicit drug use among ethnicities - 12.8%Second-highest rate of methamphetamine useAlcohol paradox –
highest rate of alcohol mortality = 638% US all races rate
highest rate of non-drinkers
SEXUALLY TRANSMITTED INFECTIONS
2nd highest rate of all ethnic groupsGonorrheaChlamydia
3rd highest rate of syphilis
HPV – Human Papillomavirus
Cause of most or all cancer of the cervix – which is one of the preventable cancers
AI/AN cervical cancer rates among highestDecreasing due to increased Pap smear screeningGardisil HPV vaccine now available
HEPATITIS
Hepatitis B – 2nd highest rate among ethnic groups
Hepatitis C – the highest rate of new cases among ethnic groups
Lack of HIV/STI Knowledge
Personal observation in the fieldAge-independentGender-independentUrban-rural independent
Add: “It won’t happen to me.”
LACK OF STD/STI KNOWLEDGE
Also related to…Level of education – low high school diploma rate
66% of Natives compared to 75% US average
Income level - 24.3% Natives living at poverty level
(2002-2004)
HIGH RATES of EMOTIONAL PROBLEMS
PTSD rates 8% US All Races 22% AI/AN 45-57% AI/AN Viet Nam vets
Surgeon General’s Report, 1999
WAITING FOR THE AX TO FALL
WHAT DO WE NEED?
WE NEED AN ACCURATE, UP-TO-DATE, CONFIDENTIAL SURVEILLANCE SYSTEM!
WHAT DO WE NEED TO KNOW? We need to know new infection rates
We need to identify the most at-risk groups: Geographic areas? IDUsers? Sexually-active youth?
We need to know where to focus our meager resources Geographic areas? IDUsers? Sexually-active youth?
THEN WE NEED TO…
TEST, TEST, TEST! EDUCATE, EDUCATE, EDUCATE! IDENTIFY BEST PRACTICES FOR CREATING
BEHAVIOR CHANGE IN EACH OF OUR VERY UNIQUE COMMUNITIES
COMMUNICATE AND PARTNER
RESOURCES AND PARTNERS Hunter Health Center Kansas AIDS Education & Training Center KDHE NNAAPC www.nnaapc.org NCUIH www.ncuih.org NIHB www.nihb.org NCAI www.ncai.org IHS www.ihs.gov CDC www.cdc.gov
RESOURCES AND PARTNERS
Office of Minority Health, Region VII US Conference of Mayors AND…?
RESOURCES
http://www.cdc.gov/hiv/resources/factsheets/aian.htm
5-page summary plus references, June, 2007
THANK YOU to Kathryn Thiessen, ARNP, and to the audience for your interest in our
community.
Recommended