Women at Risk for HIV/AIDS. November 1, 2010 UMDNJ RWJMS Department of Obstetrics, Gynecology and Reproductive Health Charletta A.

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1 Women at Risk for HIV/AIDS November 1, 2010 UMDNJ RWJMS Department of Obstetrics, Gynecology and Reproductive Health Charletta A. Ayers, MD, MPH

2 Objectives What is the prevalence of HIV in the US? Who are the at-risk Populations for HIV? Why is there a growing prevalence of HIV infection among Women? What strategies are available for prevention and early identification of women with HIV?

3 Why is it an epidemic? Nearly 30 years since the first case of Human Immunodeficiency i presented to the world Over 33.4 million people are living with HIV/AIDS in million people have died d of HIV/AIDS related deaths since 1981 UNAIDS Global Statistics September 2009

4 Case 1 JL 20 year old 2 nd year female college student presents to her gynecologist for her annual well woman visit. She is presently on oral contraception for the past 3 years. She has been a stable relationship for the past year with her male partner. She reports 3 sexual partners in the past and denies past STI s.

5 Goal Identify risk factors HIV testing

6 US Statistics 309 million People live in the United States 1.1 million 1.1 million live with HIV

7 We have come a long way Transmission rates have declined transmissions per 100 people with HIV transmissions per 100 people with HIV HIV incidence( annual number of new infections) have declined , new infections per year ,300 new infections per year Perinatal Transmissions declined 1990 s 1,000-2,000 mother to child transmissions mother to child transmissions

8 Where do things stand in the US? There are many successes but much more needs to be done Approximately 1 in 5 people living with HIV are unaware of their status CDC Estimates of new HIV infections in the United States, August Available at ww.cdc.gov/hiv/topics/surveillance/resources/factsheets/pdf/incidence/pdf

9 So Who is at Risk?

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11 Asymptomatic Adolescents and Adults at High Risk for HIV Infection Persons seeking treatment for sexually transmitted diseases Homosexual or bisexual men Past or present injection drug users Persons who exchange sex for money or drugs and their sex partners Women whose past or present sex partners were HIV- infected, bisexual, or injection drug users Persons with a history of transfusion between 1978 and 1985 Persons having unprotected vaginal or anal intercourse with > 1 sex partner Source: U.S. Preventive Services Task Force, b Source: Centers for Disease Control and Prevention, ention 2001.

12 High Risk Settings Receives health care in a high-prevalence or high-risk clinical setting STD clinics i Correctional facilities Homeless shelters Tuberculosis clinics ED units Adolescent health clinics with a high prevalence of STDs

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16 Increased risk for HIV transmission Gender Ethnicity Age

17 Gender

18 Women ¼ of Americans living with HIV are women Younger women are more likely than older women to acquire the HIV virus AIDS is a common killer of Women it is second only to cancer and heart disease Hall HI, Song R, Rhodes P, Prejean J, Qian A, Lee L, Karon J, Bookmeyer R, Kaplan E, McKenna M, Janssen R. Estimation of HIV Incidence in the United States. JAMA 2008;300:

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20 Why are Women at increased risk? Biological Societal Economic Cultural

21 Biological Factors for transmission in women Studies of serodiscordant couples have a greater efficiency of transmission of the HIV virus male to female vs. female to male Microscopic i vaginal tears after intercourse increase likehood of transmission of the virus STI s(bacterial vaginosis, herpes simplex virus and syphilis) cause inflammatory and ulcerative changes the vaginal mucosa Cohen CR, etal Increased interleukin-10 in the endocervical secretions of women with nonulcerative sexually transmitted diseases: a mechanism for enhanced HIV-1 transmission? AIDS 1999Feb 25;13(3):

22 Society s Influence on Transmission Lack of empowerment of Women Lack of Knowledge Prevention Risk of Transmission Gender Based Violence Incarceration of Women and Their Partners

23 Empowerment = Education Better educate women about the men in their communities. Promote prenatal testing, screening and prevention. Dismantle the mistrust and myths in the medical community. Create an initiative that women ARE first.

24 Do Women know their HIV status? According to data reported by Campsmith and coworkers approximately 1 in 5 HIV women (19.1%) pp y ( ) are unaware of their infection.

25 Lesbian, Bisexual Women and WSW Myth circulating that lesbians are at no risk for contracting AIDS. HIV transmission depends only on behavior and not on any particular sexual identity. HIV transmission between women has been documented d as early as CDC. HIV and AIDS: Are You at Risk? at Accessed June 6, 2006.

26 HIV/AIDS in Correctional Institutions in the U.S. In prison populations, women are 2 times more likely to be HIV-infected than men. The rate of HIV transmission in prison is unknown, but is estimated to be about 1% each year. Spaulding, A et al HIV/AIDS among inmates of and releases from US correctional facilities, 2006: Declining share of epidemic but persistent public health opportunity.plosone.2009, Nov 14(11).7558.

27 Economic Factor Poverty Single Parent Homes with Women as the primary care givers have lower incomes Lower income is associated with decreased access to healthcare Sex for Money Denning, P, DiNenno, E Communities in Crisis: Is There a Generalized HIV Epidemic in Impoverished Urban Areas of the United States? CDC August 2010

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29 Ethnicity increases the risk for HIV transmission Racial and ethnic minorities are disproportionately represented in the HIV epidemic and die sooner than Whites African Americans account for 51% of newly diagnosed infections and Hispanics account for 17%. CDC HIV/AIDS Surveillance Report 2007

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32 The diagnosis rate for Black women is more than 19 times the rate for white women Latino women are 5 times that of white women to be diagnosed with HIV Native Hawaiians and other Pacific Islanders have a rate of 7.1 AIDS cases per 100,000. American Indians /Alaskan Natives have AIDS cases nearly 3x that of white women.

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34 Age Growing number of adolescents are infected with the HIV virus One Quarter of new HIV infections occur among adolescents and young adults (ages 13 to 29) CDC. Estimates of new HIV infections in the United States. August

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38 Strategies for Prevention Adolescents need accurate and age appropriate information on the HIV virus School Based Programs Community Based Programs Parent/Child Education Programs

39 School Based Programs Task Force of the National Campaign to Prevent Teen Pregnancy reviewed evidence for effective programs Successful programs were defined as research evidence of delayed sex or increased condom use

40 Successful Programs Becoming a Responsible Teen: An HIV risk reduction Intervention for Adolescents Making a Difference: An Abstinence Approach to STD, Teen Pregnancy, HIV risk Making Proud Choices: Reducing the Risk: Building Skills to Prevent Pregnancy, STD and HIV Safer Choice: Prevention of HIV, Other STD s and Pregnancy

41 How is your state impacted by HIV? The South and Northeast along with Puerto Rico and the US Virgin Islands are disproportionately p impacted by HIV CDC HIV/AIDS Surveillance Report 2007

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44 Factors which make the South the hardest hit area for Women with HIV Increase of African American women who live in the south Poverty and gender inequality Limits on education attainment Women with limited it power Gender-based violence Alcohol and drug use Depression

45 Healthcare Providers Every 35 minutes a woman tests positive for HIV in the United States t N ti l W H lth I f ti C t US D t t f H lth d National Women s Health Information Center. US Department of Health and Human Services. Office of Women s Health. Womenshealth.gov

46 What we can do as providers? Eliminate the discrimination and stigma in HIV testing. Seize the moment at each office visit, clinic visit, hospital ED s, urgent care clinics, correctional healthcare facilities, prenatal clinics, substance abuse treatment centers, sexually transmitted disease clinics! i

47 What we can do as providers? Adopt the CDC s recommendation of routine testing which has been endorsed by the: American College of Physicians; and American Congress of Obstetricians and Gynecologist. HIV screening should be a part of routine clinical care in all health-care settings for persons aged 13 to 64 years of age and to all pregnant women.

48 What we can do as providers? The CDC recommends eliminating requirements for consent to HIV testing and pretest counseling. opt-out" testing meaning the patient is notified that the test will be preformed unless the patient elect s to decline or defer testing MMWR S t ( 14) 1 17 i d id li f HIV/AIDS t ti Ad lt MMWR Sept (rr14) 1-17 revised guidelines for HIV/AIDS testing Adults Adolescents and pregnant women

49 Case 2 PA 19 year old African American female who was followed by our GYN clinic for cervical dysplasia from She was evaluated at 8 weeks of birth for thrush and found to be positive for HIV. PA s Mother was also tested and found to be HIV.

50 Socially PA was in a group home She had multiple admissions for Pneumonia 2006 PA died an AIDS related Death

51 Goal Prevention of transmission of HIV at birth

52 Prenatal Screening

53 Prenatal HIV Transmission Accounts for nearly all pediatric AIDS cases: Approximately 91% of all AIDS cases reported among U.S. children between 1985 and Can be prevented: 2% risk with appropriate treatment compared with approximately 25% when no interventions are given. MMWR 1999;48 (19):

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55 Universal Opt Out Screening All pregnant women should be screened Before screening, explain opt out process: HIV screening recommended for all pregnant patients; and HIV testing is part of routine panel of prenatal tests unless declined (opt-out screening). Testing must be voluntary & free from coercion. No woman should be tested without her knowledge. MMWR Sept (rr14) 1-17 revised guidelines for HIV/AIDS testing Adults Adolescents and pregnant women

56 Pregnant Woman with an HIV-Infected Male Partner Test for HIV (unless declined) 2 nd test 3 rd trimester, before 36 weeks (if possible) If presents in labor: rapid HIV test If seroconversion suspected, do HIV RNA & antibody test; repeat HIV test in 4-6 weeks HIV+ interventions to perinatal transmission HIV- counsel about HIV risk reduction U.S. Public Health Service Perinatal Guidelines November 2007

57 Today, women with HIV who get treatment are living longer and staying healthier. What can a pregnant woman with HIV do to protect her health and her baby? If a pregnant woman has HIV, she can take action to protect her health and her baby. Drugs are now available that can improve the woman's health, prolong her life, and help prevent her baby from getting HIV. A woman with HIV may have surgery (cesarean or C section) to help protect her baby from the disease. A doctor or nurse can talk with her about this option. It's important to remember that HIV can pass through breast milk. So if a woman has HIV, she should not breastfeed.

58 Out of 50 pregnant women with HIV, the risk of passing HIV to their babies is about: When women begin treatment during pregnancy 1 baby out of 50 When women begin treatment t t during labor, or their babies get treatment soon after birth, or they both get treatment at these times 5 babies out of 50 When women do not get treatment 13 babies out of 50

59 Pre-conception Screening

60 Early Diagnosis in Pregnancy HIV screening should be routine in the medical care of women prior to pregnancy. It is part of preconception care. Becoming pregnant w/o knowing HIV status = important missed prevention opportunity.

61 Community Education National Women and Girls HIV/AIDS Awareness Day 2010 The numbers are unsettling: More than 278,000 women and adolescent girls in this country are living with HIV. Almost 94,000 American women and girls with AIDS have died since the epidemic began.

62 Resources One Test 2 Lives Campaign Campaign by the CDC Supporting Women and their providers for screening and treatment of pregnant women CDC.gov

63 Toward Elimination of Disparities in HIV Prevention and Early Diagnosis Strategies Media campaigns-black, Latino Radio and TV Decrease focus on high risk behavior Greater than AIDS Campaign 1 Educate youth Comprehensive Sexual lhealth lthcurricula should ldbe mandatory in public schools 1 Greater than.org~

64 National Strategy Washington, D.C., July 13, 2010 APHA applauds today s release of the Obama administration s National HIV/AIDS Strategy, the nation s first-ever comprehensive plan to address the HIV/AIDS epidemic i facing our country.

65 We can make a difference Awareness Community Increased Risk Groups Providers Increase Availability and Knowledge of Testing

66 Thank you.

67 Future