HIV Prevention: Update 2005

Barbara Weis, MD, MPH &TM

Julie Bender, LCSW-C

Robbin Alexander, HIV Outreach Worker

Sinai Hospital of Baltimore

November 1st, 2005

HIV Prevention: Update 2005

HIV prevalence and deaths will continue to increase without effective interventions.

Some progress has been made in prevention, but much more work is needed.

What can be done by primary care and ED providers?

Adults and children estimated to be Adults and children estimated to be living living

with HIV as of end 2004with HIV as of end 2004

Total: 39.4 (35.9 – 44.3) million

Western & Central Europe

610 000610 000[480 000 – 760 000][480 000 – 760 000]

North Africa & Middle East540 000540 000

[230 000 – 1.5 million][230 000 – 1.5 million]

Sub-Saharan Africa25.4 million25.4 million

[23.4 – 28.4 million][23.4 – 28.4 million]

Eastern Europe & Central Asia1.4 million 1.4 million

[920 000 – 2.1 million][920 000 – 2.1 million]

South & South-East Asia7.1 million7.1 million[4.4 – 10.6 million][4.4 – 10.6 million]

Oceania35 00035 000

[25 000 – 48 000][25 000 – 48 000]

North America1.0 million1.0 million

[540 000 – 1.6 million][540 000 – 1.6 million]

Caribbean440 000440 000

[270 000 – 780 000][270 000 – 780 000]

Latin America1.7 million1.7 million

[1.3 – 2.2 million][1.3 – 2.2 million]

East Asia1.1 million1.1 million

[560 000 – 1.8 million][560 000 – 1.8 million]

Estimated number of children (<15 years)

newly infected with HIV during 2004Western & Central

Europe< 100< 100[< 200][< 200]

North Africa & Middle East9 1009 100

[2 800 – 30 000][2 800 – 30 000]

Sub-Saharan Africa560 000560 000

[500 000 – 650 000][500 000 – 650 000]

Eastern Europe & Central Asia1 8001 800[1 200 – 3 700][1 200 – 3 700]

East Asia4 1004 100[1 500 – 11 000][1 500 – 11 000]South

& South-East Asia51 00051 000[30 000 – 95 000][30 000 – 95 000]

Oceania< 300< 300[< 1 000][< 1 000]

North America< 100< 100[< 200][< 200]

Caribbean6 1006 100

[3 100 – 13 000][3 100 – 13 000]

Latin America6 8006 800

[5 400 – 11 000][5 400 – 11 000]

Total: 640 000 (570 000 – 750 000)

About 14 000 new HIV infections a day in 2004

More than 95% are in low and middle income countries

Almost 2000 are in children under 15 years of age

About 12 000 are in persons aged 15 to 49 years, of whom:— almost 50% are women— about 50% are 15–24 year olds

Global AIDS Funding

By 2007, $20 billion will be needed. ART to 6 million. Support for 22 million orphans. HIV counseling and testing for 100

million adults. School-based AIDS education for 900

million students. Peer counseling for 60 million young

people not in school.

Impact of HIV in Africa

8% drop in GDP by 2010; 20% drop by 2020.

>50% of all illnesses among workers were AIDS-related.

7 million farm workers have died from AIDS.

85% of teacher deaths are from AIDS.

Life expectancy of sexually active Ugandans has fallen from 64 to 42 years.

The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India

and China NIC Report ICA2002-04D

Sept. 2002

“ We project China will have 10 to 15 million HIV/AIDS cases, and India is likely to have 20 to 25 million by 2010—the highest estimate for any country.” (2004 UNAID Estimate: 4-5 million)

Baltimore: Incident HIV and AIDS Deaths among HIV and AIDS

Baltimore: Incident AIDS Cases by Race/Ethnicity

Baltimore: Incident AIDS Cases by Gender

HIV/AIDS in Baltimore City: Adjusted

Zip Pop.-2000 HIV Incidence Prevalence HIV/AIDS

7/1/03-6/30/04 on 6/30/04 %pop

21208 25,513 1= 0.004% 7= .03%

21211 13,536 11= .08% 134= 0.99%

21215 53,750 76= 0.14% 1324= 2.46%

21216 29,356 49= 0.17% 802= 2.7%

21217 33,725 125= 0.37% 1662= 4.9%

HIV Prevention: Based on the Mechanisms of Transmission

Biological: Vaccination*. Treatment of STDs. Circumcision*. Topical microbicides*. Treatment with ARVs, Prophylaxis.

Behavioral: Voluntary counseling and testing. Education and behavioral modification. Drug Abuse Treatment, clean syringes. Condoms *not proven

effective.

Hope for a Vaccine

Monkeys have shown complete or partial protection after vaccination.

Successful vaccines have been developed against other retroviruses.

Almost all humans develop an immune response to HIV.

Some exposed people remain uninfected despite exposure or develop protective immune responses which contain the virus for long periods.

HIV Vaccine: Biology

Natural infection results in an immune response which doesn’t clear the virus.

Genetically diverse: HIV-1 and HIV-2. Different clades, or subgroups, are in

different geographic regions of the world. Rapid mutation. HIV vaccine must produce mucosal (STD)

and systemic immunity(blood). Currently, more than 30 candidate are

being tested in 19 countries on six continents.

HIV Vaccine Challenges

Pipeline of vaccines is narrowly focused on cell-mediated hypothesis.

Vaccines are difficult to manufacture. Results from cell-mediated hypothesis

not due till 2007. If this fails, the pipeline now in trials will be irrelevant.

No global consensus about which are most deserving of large-scale trials.

May need to settle for improved clinical control of disease, not complete prevention.

HIV Vaccine: Ethical Challenges

Rich countries have the expertise and resources, but do not have sufficient numbers of patients for clinical trials.

Poor countries have patients but poor infrastructure and inadequate resources.

History of abuse of vulnerable people in clinical trials.

May require a prime/boost method to stimulate CTL and antibody response.

HIV Vaccine: Ethical Challenges

The first vaccine may be no more than forty or fifty per cent effective.

Will vaccination increase high-risk behavior?

The second vaccine will not be able to be tested against placebo, but against the first vaccine, causing logistical nightmares.

The rate of childhood vaccination in Uganda declined from 47% in 1995 to 35% in 2002.

The cost of the vaccine may be $1000.

HIV Vaccine: Ethical Challenges

Should every infected participant receive the best care available: Western or African?

Will subjects benefit from the research? If all vaccine recipients become HIV+,

what about future screening methods? Discrimination?

Political instability?

Prevention: Perinatal HIV Gold Standard

Universal screening of pregnant women. Prenatal, peri-and postnatal antiretroviral

therapy. Rapid testing in the delivery room of

patients whose HIV status is unknown. Appropriate elective caesarean section. Formula for the newborn.

Enhanced Perinatal Surveillance: Baltimore City

10% diagnosed during labor; 25% no risk factor. 80% received ART during pregnancy, 67%

during labor. 55% had positive drug screens during

pregnancy. 91% had at least one prenatal care visit, only

17% began PNC during 1st trimester. HIV neg infants :

Mothers more likely to start PNC in 1st trimester (58vs 17%).

100% of infants received 6 weeks ART.

Prevention: Perinatal HIV2004

N America & W Eur

<100 new cases <2% transmission

if prenatal care and antiretroviral therapy

Formula feeding <100 deaths from

AIDS under age 15 in 2004

Sub-Saharan Africa

560,000 new cases 25-40%

transmission with no treatment

Breastfeeding 14-40% additional risk

59% HIV-infected infants die by 18 months

Perinatal Prevention: Resource Poor

Thailand: Not breastfeeding: 18 months. 1.9% with ZDV at 28 weeks plus single

dose Nevirapine (NVP), 2.8% at with ZDV +3TC .

Ivory Coast,Africa: breastfeeding: 24 mths. 22.5% with short-course ZDV vs. 30%

placebo, 15.7% at 18mths. forNVP. Increased transmission: genital ulcer

disease, chorioamnionitis, mastitis and malnutrition.

Antiseptic washes: may help since 2/3 of transmission after 36 weeks.

Mother to Child Transmission: Breastfeeding

Breastfeeding adds 14-40% additional risk.

Breastfeeding accounts for 1/3 of HIV infections in children.

Exclusive breastfeeding is better than “mixed” feeding.

In Kenya, formula feeding decreased postnatal transmission by 40%, but still mortality 24% BF vs. 20% formula.

May require ART prophylaxis.

Barriers: Perinatal HIV Prevention

Antiretrovirals have significant side-effects: anemia, neutropenia, pancreatitis and neuropathy, lactic acidosis.

Lack of prenatal care. Reluctance to be tested. Women may develop resistance,

especially to Nevirapine. Lack of money for antiretrovirals. Prevention programs reach only 20% of

targeted population..

Four priorities:

1. Make voluntary HIV testing a routine part of medical care

2. Implement new models for diagnosing HIV infections outside medical settings

3. Prevent new infections by working with persons diagnosed with HIV and their partners

4. Further decrease perinatal HIV transmission

Behavioral prevention: CDC: New Strategies for a Changing

Epidemic

MMWR April 18, 2003

Social Context, Sexual Networks and Transmission

Concurrent partnerships increase transmission. 53% in black men vs. 21% in black

women vs. 11% white women. Shortage of men causes low marriage

rates and higher divorce rates, decreasing monogamous relationships. Affects power balance.

US has one of the highest incarceration rates in the world. HIV in inmates is 8-10 times higher.

HIV infected 850,000-950,000

Unaware of HIV infection 180,000 - 280,000

Awareness of Serostatus among

Persons with HIV, United States

HIV Testing in the Emergency Room: The Need

High risk populations use the ED as their only source of health care.

During 1994-1999, AIDS was diagnosed in 41% of persons within one year of their first positive test. High risk populations use the ED as their only source of health care.

Knowledge of status changes behavior: 78-96% used a condom with a known Neg. partner, 52-86% with a partner of unknown status.

HIV Testing in the Emergency Room

Less than 3% of Eds routinely test for HIV.

Recognition of acute HIV: in a Universtiy ER, 0.8% of Monospots positive for acute HIV.

High acceptability of testing in the ED (50%).

Decline testing: higher rates HIV. Early awareness of HIV status is the first

step in obtaining medical care.

HIV Testing in the Emergency Room

Lack of time, privacy, and follow-up, language and cultural barriers need to be overcome.

May need to “de-couple” HIV tests from extensive pre-test prevention counseling.

Combined antibody and RNA testing of pooled specimens may be helpful.

Targeted screening (IDU, STDs, African American) may miss 25% of new infections.

HIV prevalence of 1%: CDC recommends testing all patients aged 18 to 54 years.

Physicians in Practice: More needs to be done

In a 2002 survey of 4226 physicians, 24% routinely screened men, 30% routinely screened women for

HIV. Only 80% of OB/GYNs routinely screened

all pregnant women. Only 20-30% verified that partners had

been referred for testing.

Advancing HIV Prevention: The Four Strategies

Four priorities:

1. Make voluntary HIV testing a routine part of medical care

2. Implement new models for diagnosing HIV infections outside medical settings

3. Prevent new infections by working with persons diagnosed with HIV and their partners

4. Further decrease perinatal HIV transmission

Outreach Testing Sites

Chemical Dependency Programs

Homeless shelters Sex worker support

program Drop-in center for

gay youth Teen clinic Gay bars

Sex offender groups

“Johns” programs Half-way houses Health fairs Strip club workers African-born

groups Drug court

support groups

Four FDA-approved Rapid HIV Tests

99.7 (99.0 – 100) 99.8 (99.3 – 100)

100 (99.5 – 100)

100 (99.5 – 100)

Uni-Gold Recombigen

- whole blood

- serum/plasma

100 (99.7-100)

99.8 (99.6 – 99.9)

99.9 (99.6 – 99.9)

99.6 (98.5 - 99.9)

99.3 (98.4 - 99.7)

99.6 (98.5 - 99.9)

OraQuick Advance - whole blood

- oral fluid

- plasma

Specificity

(95% C.I.)

Sensitivity

(95% C.I.)

Confirmatory Testing

Confirmatory test essential (not just EIA!)

For Western blot: Venipuncture for whole blood Oral fluid specimen

Follow-up testing of persons with negative or indeterminate Western blot results after 4 weeks

Advancing HIV Prevention: The Four Strategies

Four priorities:

1. Make voluntary HIV testing a routine part of medical care

2. Implement new models for diagnosing HIV infections outside medical settings

3. Prevent new infections by working with persons diagnosed with HIV and their partners

4. Further decrease perinatal HIV transmission

Prevention: Persons Living with HIV

Outreach for preventive care services. Screening for return to high-risk

behavior. Ongoing prevention messages. Referral for treatment: substance abuse,

depression. Facilitating partner notification,

counselling and testing. Identifying and treating STDs.

HIV Prevention: Update 2005

HIV Prevalence and deaths will continue to increase without effective interventions.

Some progress has been made in prevention, but much more work is needed.

More can be done by primary care and ED providers.

RESTRICTEDUnder 17 requires accompanying parent or adult guardian.For strong language,drug use and sexuality.

Do You Know What Your Child Knows?

Goal by 2010: 90% of schools will provide education about unintended pregnancy, HIV/AIDS, and STDs(baseline 65%).

The percentage dropped to 62% in 2000. Current administration's focus is on

abstinence-only prevention and the small risk that a condom may not prevent infection.

Montgomery County updated health ed curriculum: homosexuality and condom demonstrations.

Case Report

AJ is a 20 year old African American male who has been followed at Greenspring Pediatrics since birth. He presented two months ago when he was informed by the Red Cross after a blood donation that he was HIV+.

He has had yearly check-ups since birth. In all of the previous check-ups, he had denied any sexual activity.

He continued to deny all sexual activity until a social work consult was obtained. He disclosed that he had had sex with men.

Adolescent Risk Behavior

The notion of “risk groups” is not useful among adolescents.

Most adolescents engage in some type of risk taking behaviors: experimentation with tobacco, drugs and sex is common.

The most commonly abused drug among adolescents is alcohol.

CDC Youth Risk Behavior Surveillance High School

Students 1999 Sexual and Contraceptive Behaviors: Sexual Intercourse:

50% had sexual intercourse during their lifetime.

36% had sexual intercourse in the previous 3 months.

16% had 4 or more lifetime sexual partners. 8% had first sexual intercourse at age < 13

years.

Condom Use: 58% reported condom use during last sexual

intercourse. Consistent condom use not examined.

CDC Youth Risk Behavior Surveillance High School

Students 1999 Alcohol and Other Drug Use Alcohol:

Lifetime use- 81% at least one drink Current use- 50% one drink in the previous 30

days

Marijuana Lifetime use- 47% used marijuana Current use- 27% used marijuana previous 30

days

Adolescent Risk Behavior

Sexual behavior is often not the same as sexual identity.

Female adolescents often use anal intercourse to prevent pregnancy and maintain cultural standards of “virginity”, unaware they are engaging in the highest risk sexual behavior for HIV transmission.

Components of Effective HIV Education

Open-ended questions and non-medical language.

Repetition and reiteration. Non-judgmental approach to sexual or

drug related topics. Interactive exchange of information. Condoms, condoms, condoms.

Condom Education

Demonstration with a condom on the arm, a banana..etc. (have condoms to give out.).

Detailed explanation of when to use a condom (before any sexual contact.).

Discuss barriers to condom use. Conversation needs to happen at every

visit.

Does Prevention Education work?

In 1998, CDC trial enrolled 6,000 heterosexual men and women attending STD clinics in Baltimore, Denver, Long Beach, Newark and San Francisco.

When counsellors “encourage” &

“discuss” prevention strategies rather than simply provide a “lecture” on HIV prevention, it significantly reduces their risk of STDs.

Does Prevention Education work?

When counsellors talked with, rather than to, men and women at risk, 20% fewer men and women and 40% fewer adolescents developed new STDs the next year.

The “encouragement” approach was

as effective in two brief 20- minute encounters as in a more extensive 4-session program.

HIV/AIDS Prevention, December1998.

HIV Outreach Strategies

Effective Outreach Strategies include: Giving the facts Being honest Gaining trust Being non-judgmental Listening

Barriers to Effective Community Outreach

Stigma about HIV and getting tested. Lack of Medical insurance. Fear of being judged. Little or no knowledge of HIV/AIDS. Little knowledge of community

resources.

Impact of HIV Outreach in the Community

It supports and encourages more people to get tested for HIV.

Encourages and supports change in sexual and drug using behaviors.

Educates people about HIV and it’s impact.

Helps young people make better choices.

Outreach in the Community

HIV outreach and prevention education should be done in: Schools Community Centers Recreational Centers Churches Community Clinics Health Fairs Any appropriate groups