11/8/2016. The Challenge of HIV Treatment

Transcription

1 You Mean I Have to Talk About...Sex? Trudy Larson, MD Professor and Director, School of Community Health Sciences Medical Director, Nevada AIDS Education and Training Center Nat l HIV/AIDS Strategy Goals 1. Reduce the number of people who become HIV infected 2. Increase access to care and optimize health outcomes for people living with HIV 3. Reduce HIV related health disparities discrimination and stigma AND ALL OF THESE GOALS ARE DEPENDENT ON TALKING ABOUT SEX! The Challenge of HIV Treatment Only 28% of HIV+ are adequately managed Spectrum of engagement in HIV Care in the United States Gardner, CID, CDC, Vital signs: HIV prevention through care and treatment United States,

2 Universal HIV Testing CDC recommendations for HIV testing in health care setting Includes public and private settings and calls for: Routine testing in emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, correctional health care facilities and primary care settings Testing of all persons ages (not at risk) as a screening tool Now endorsed by the US Preventative Task Force! NOT REALLY FULLY IMPLEMENTED IN ALL VENUES Does this mean I don t have to talk about sex? Just test them????? A. True B. False Does that mean I don t need to ask about Sex? Just test them? The answer is FALSE. Need to identify ongoing risk if positive or negative and help them maintain health. Everyone should have the opportunity to be tested Currently access is higher for females because of routine testing during pregnancy Need to expand opportunities for men to include other sites of care Where there is one STI there may be others... 2

3 Why Should Everyone Be Tested? 18% of people living with HIV do not know they are infected Natural history of disease results in long infectious, asymptomatic period (years) There are no symptoms for an average of 10 years. Only testing will identify infection except in advanced cases of AIDS Early entry into care increases the chance of a longer healthier life because medications work well. Now approx 39% of persons with HIV are not diagnosed until they are in the late stages of disease Medication significantly improves all outcomes Transmission rates are higher in people who do not know they have HIV Those who know they have HIV are more likely to engage in risk reduction efforts Awareness of Serostatus Among People with HIV, and Estimates of Transmission ~25% Unaware of Infection ~75% Aware of Infection accounting for: ~54% of New Infections People Living with HIV/AIDS:1,200,000 ~46% of New Infections New Sexual Infections Each Year: ~50,000 Adapted from Marks et al, AIDS, Plasma HIV RNA Predicts Likelihood of HIV Transmission Transmission rate per 100 personyears All subjects Male to Female Transmission Female to Male Transmission Viral load (HIV 1 RNA copies/ml) and HIV transmission Quinn et al. N Engl J Med

4 Why Test Routinely for HIV? Other Benefits. Routine testing is recommended to reduce stigma and increase rate of diagnosis Risk assessment often not done Risk prevention is rarely addressed Lack of knowledge Lack of comfort Testing offers opportunity to discuss risk How comfortable are you discussing sex with your patients? A. I have no problems B. I d rather have my toenails pulled out slowly C. I m not comfortable because I don t know what to say D. As long as they re not the same age as my children, I can do this Do Providers Ask About Risk? PRIMARY CARE PROVIDERS % of Providers Who Assessed STD Risk N=208 providers PRIVATE PHYSICIANS NON-INFECTIOUS DISEASE TRAINED PHYSICIANS INFECTIOUS DISEASE TRAINED PHYSICIANS HIV CARE PROVIDERS N= 12.7 million visits N= 317 physicians N= 317 physicians N= 417 providers Primary Care Providers Bull 1999 Private Physicians Tao 2003 Non-ID trained Physicians Duffus 2003 ID trained Physicians Duffus 2003 HIV Care Providers Metsch 2004 Ongoing care 4

5 Discomfort as a Barrier Ironically, it may require greater intimacy to discuss sex than to engage in it. The Hidden Epidemic Institute of Medicine, 1997 Scale of embarrassment..1(least) 5(most) How to do Risk Assessment Question 1: Do you have sex? YES or NO. If NO, you are done with your interview. If YES, Do you have sex with men, women or both? What kind of sex do you have? ORAL. ANAL. VAGINAL. What kind of protection do you use? 5

6 Bad communication can happen Nuances of asking about protection You might expect to hear about condoms You need find out how often they are used, how the person feels about it, and if there are any barriers to use. You may also hear about the female condom Do you know how it is used? Female Condom 6

7 Most creative use of a female condom Nuances of asking about protection You might expect to hear about condoms You need find out how often they are used, how the person feels about it, and if there are any barriers to use. You may also hear about the female condom Do you know how it is used? Often you may hear that the other person won t use protection Need to ask about issues regarding non use Male partner refuses Interrupts pleasure Power struggles Do not be judgemental!!!!! Listen and try to help problem solve 7

8 What to do with the responses you get Plan of action May need to routinely get them to come in for STI screening Every 3 6 months depending May need to prescribe PrEP May need to find them resources to deal with abuse, violence, and other social issues that make them vulnerable Consider incremental behavior changes Small initial goals to increase the use of protection or practice risk reduction Frequent discussion of successes and problems (remember the nonjudgmental stuff) Don t forget routine HIV testing either OMG, I think I can talk about anything with anyone! A. I agree with this statement B. I m mostly OK with this statement C. This is NOT me at all D. I can relate to all ages OMG, I think I can talk about anything! What does this emoji mean? 8

9 OMG, I think I can talk about anything! What does this emoji mean? OMG, I think I can talk about anything! What does this emoji mean? Being Non judgmental is very important! Do not roll your eyes! Do not looked shocked! Do not look afraid! 9

10 Figure out your best way to introduce the Sex talk with your patients.. Ex: I ask these questions of all my patients Ex: Let them fill out the questions (on paper, on computers, etc.) while they wait and then you can just respond to them Ex: We are screening everyone in our clinic/office/practice for HIV. Do you have any questions? Ex: Best practices for taking care of patients now includes asking about sex. I ll start with a simple question. Not a good Ex: I m supposed to talk with you about sex but if you don t want to then I guess we can do it another time or if you have any questions maybe I can answer them now but really I don t have enough time Early Diagnosis and Prevention Testing starts the cascade and diagnosis allows for more prevention options to reduce transmission Innovative testing initiatives Prevention with Positives Behavioral risk reduction Treatment as Prevention Prevention with Negatives PrEP with MSM PrEP with discordant heterosexual couples PrEP with IV drug users So if I prescribe PrEP, can I then forget about doing sexual assessments? A. True B. False 10

11 How to Use PrEP? Ask about sexual risk Not all people should be offered PrEP Must understand that use of PrEP does not protect against other STI Need to identify risk behaviors to tailor conversations Need to see regularly Recommendation to see quarterly and do regular evaluation Include HIV testing, STI testing, Chemistry panel to assess for toxicities Need to ask about symptoms of STIs and do counseling to reduce risk of other STI Need to discuss adherence (need at least 4 doses a week for men and 6 doses a week for women) Just a reminder, early diagnosis can inform prevention Testing is the key to starting the cascade Early diagnosis provides the opportunity to intervene to: Link to care and treatment Reduce morbidity and mortality Take precautions to reduce transmission through treatment and through behavioral changes Allows for those who are negative to take steps to reduce their risk How can you incorporate this into your practice? A. Just start doing sex assessments B. Work with staff to incorporate as routine C. Pick out the dialog I want to use D. I just don t think I can do this 11

12 Bottom line: Need to plan and practice Figure out routine language to use that you are comfortable using Make sure you say that you ask about this routinely Consider how you will respond to issues Use of condoms (both types) Need for PrEP Ongoing risk Be non judgmental in all conversations not Incorporate HIV testing (as screening) as a routine practice and be ready to follow up 12