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.