Care of Women with HIV Living in Limited-Resource Settings

Prevention
Jean R. Anderson, MD Director Johns Hopkins HIV Womens Health Program

Resources
A Guide to the Clinical Care of Women With HIV: 2001 First Edition
To request the guide, send e-mail to ask@hrsa.gov

Care of Women With HIV Living in LimitedResource Settings tutorial series

For more information about the HIV tutorial series, send e-mail to hiv-aids@jhpiego.net.

Learning Objectives
Why prevention is important Progress made in HIV prevention Modes of HIV transmission Most effective interventions for reducing transmission

Performance Objectives
Explain why prevention is important Demonstrate progress made in HIV prevention Discuss the modes of HIV transmission Describe the most effective interventions for reducing transmission

Risk Perception: Percentage of Sexually Active Women (1519) Who Think They Are not at Risk of Getting AIDS
Guatemala Brazil Niger Chad Mali Togo Haiti Kenya Uganda Zambia Zimbabwe
0 20 87% 52% 87% 60%

46% 45% 63%

36%

21%
52% 50% 40 60 Percentage 80 100

Source: UNICEF 1999

Risk Perception: Percentage of Sexually Active Women (1519) Who Think They Are not at Risk of Getting AIDS
Guatemala 1% Brazil 1% 52% 1% Niger Chad 2% 60% 3% Mali 46% 7% Togo 45% 10% Haiti 63% 16% Kenya 36% 19%21% Uganda 27% Zambia 52% 30% Zimbabwe 50%
0 20 40 60 Percentage 80 87% 87% HIV prevalence rate in women attending antenatal care clinics in major urban areas (at time of survey) 100

Source: UNICEF 1999.

Trends in HIV Prevalence in Selected Populations

Kampala, Uganda, < 20 year old antenatal clients1
25

Thailand, 21 year old military conscripts2 Dakar, Senegal, all ages antenatal clients1

HIV prevalence (%)

20

15

10

0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Source: 1National STD/AIDS Control Programmes; 2Armed Forces Research Institute of Medical Sciences

Percentage Sexually Experienced by Current Age (1524 years old) in 1989 and 1995 Uganda
100

% Sexually Experienced

75

50

Women 1989 Men 1989 Women 1995 Men 1995

25

0 15 16 17 18 19 20 Age 21 22 23 24

Source: UNAIDS 2001.

Substantial and Sustained Risk Reduction in Urban Males Visiting Sex Workers 19901997 Thailand
50 45 40 35 30 25 20 15 10 5 0 Age 20-24 Age 25-29

% Visiting Sex Workers in 12 months

1990 1993 1997

Sources: Sittitrai et al, Thongthai et al, Chamratrithirong et al. Need dates

Modes of Transmission
Sexual most common mode of transmission globally Risk per episode
Receptive vaginal intercourse: 0.10.2% Receptive anal intercourse: 0.13% Insertive vaginal intercourse: 0.1% Insertive anal intercourse: 0.06% Receptive oral intercourse: 0.04%

10

Factors Affecting Sexual Transmission of HIV

Infectiousness Susceptibility

Late Clinical Stage

Primary HIV Infection Antiretroviral Therapy Genital Tract Infection Cervical Ectopy Circumcision Method of Contraception Barrier Hormonal Spermicidal IUD Menstruation Pregnancy
Source: Royce et al 1997.

N/A
N/A ?

? ? ?

11

Modes of Transmission
continued

Parenteral
Transfusion: 95% risk of infection with single unit of whole blood Injection drug use: 0.67% risk per exposure Healthcare workers (needlestick): 0.4% risk per exposure

12

Modes of Transmission
continued

Perinatal
2530% risk of transmission without antiretroviral therapy or scheduled cesarean section

Traditional practices
Circumcision, ear piercing, tattooing, ritual scarification with shared and non-sterile or nondisinfected instruments

13

Modes of Transmission
continued

HIV is NOT transmitted by:

Insect bites Kissing Hugging Touching toilet seats Sharing eating utensils
14

HIV Prevention What Works?

Voluntary counseling and testing (VCT)
Risk assessment Risk reduction Testing

Behavioral interventions to reduce risk behavior Condoms (dual protection or dual use) Sexually transmitted infection (STI) prevention and treatment
15

HIV Prevention What Works?

continued

Antitretroviral (ARV) and breastfeeding interventions to prevent mother-to-child transmission (MTCT) Safe transfusion practices

16

Reasons to Provide HIV Counseling and Testing

Knowledge of HIV status can benefit HIVinfected persons
Treat and prevent opportunistic infections Prevent of MTCT Reduce risk of transmission to others Help plan for future Provide access to antiretroviral therapies as these become available

HIV prevention counseling is effective at reducing risky behaviors in HIV-infected and 17 uninfected persons

Behavioral Interventions
Education Recognition of risks Recognition of barriers to risk reduction Motivation to change Risk reduction plan

18

Risk Assessment
Age < 25 yrs Single Sexual behavior: woman or partner
More than one partner in last 3 months Multiple partners New or casual partner

STIs: woman or partner

History Signs or symptoms

Mobile population
Refugee Husband in military or long-distance truck driver

History of substance abuse Pregnant History of tuberculosis (TB) Sex worker Signs or symptoms 19 suggesting HIV

Ways to Reduce Risk of Transmission

Sexual behavior
Abstain from or delay start of intercourse Decrease number of sexual partners Practice monogamy Practice non-penetrative sex Avoid:
Anal sex Douching Dry sex Sex during menses Sex while using alcohol/drugs

Use condoms with every sexual act

20

Condoms
Most effective method to prevent HIV transmission and STI acquisition Male and female condoms available Clients should be instructed in proper use Consistent use must be emphasized

Male Condom

Female Condom

21

Percentage of Sexually Active Men and Women Who Have Ever Used a Condom, Urban Uganda, 1989 and 1995
70

% Ever-Used Condoms

60 50 40 30 20 10 0 15-19 20-24 25-39 Age Groups 40-49 All

22

Women 1989 Men 1989 Women 1995 Men 1995

Source: UNAIDS 2001.

Dual Protection
Dual protection: Protection against pregnancy, HIV and other STDs Achieved by:
Avoidance of penetrative sex Mutual monogamy between non-infected partners using effective contraception Condom use alone Dual method: Condom use in combination with other contraceptives
23

Dual Protection continued

Used correctly and consistently with every act of sex, condoms are 98% effective in protecting against HIV and STDs and 95 97% effective in preventing pregnancy

24

Female Condom versus Male Condom

Male Condom
Made from latex; some also from polyurethane

Female Condom
Made from polyurethane

Fits on the penis

Lubricant: Can include spermicide Should be water-based only for latex Located on the outside of condom Covers most of the penis and protects the womans internal genitalia Latex condoms can decay if not stored properly; polyurethane condoms are not susceptible to deterioration from temperature or humidity Condom must be put on an erect penis Must be removed immediately after ejaculation Should not be reused

Loosely lines the vagina

Lubricant: Can include spermicide Can be water-based or oil-based Located on the inside of condom Covers both the womans internal and external genitalia and the base of the penis Polyurethane condoms are not susceptible to deterioration from temperature or humidity

Can be inserted prior to intercourse - does not require erect penis Does not need to be removed immediately after ejaculation Can be safely reused if washed, rinsed and air dried after initial use 25

Source: UNAIDS 2000.

Protection Against HIV Offered by Other Contraceptive Methods

Spermicides
May have activity against gonorrhea, chlamydia Possible increase in mucosal irritation and genital ulcers, especially with frequent use Recent UNAIDS clinical trial of sex workers in Africa and Thailand found significantly higher HIV seroconversion rates in nonoxynol-9 users as compared to a placebo vaginal lubricant
26

Protection Against HIV Offered by Other Contraceptive Methods continued

Diaphragm
No significant protection against HIV transmission Limited STI protection

27

Protection Against HIV Offered by Other Contraceptive Methods

continued

IUD
No STI or HIV protection Increased menstrual flow and duration with nonprogesterone containing IUDs may increase transmission risk and risk of anemia No increase in cervical HIV shedding four months after insertion.

28
Source: Richardson 1999.

Contraception and Prevention of HIV Infection continued

Hormonal methods: oral contraceptive pills, DMPA, Norplant implants
No significant STI or HIV protection May increase genital tract HIV shedding

Voluntary sterilization
No STI or HIV protection Decreased risk of PID
29

STIs Prevention and Treatment

STIs, both ulcerative and nonulcerative, facilitate HIV transmission 25 fold

Condoms Sexual behavior change Recognition of risk factors and early symptoms Syndromic management
Genital ulcer disease Urethral discharge in men Vaginal discharge limitations

30

STIs Prevention and Treatment

continued

Antenatal screening for syphilis Linkage to programs treating symptomatic men Target high-risk individuals
Sex workers and clients Drug users Military personnel Truck drivers

31

Rates of STIs Among Pregnant Women in Dakar, Senegal, 19911996

35 30.1 30

STD Prevalence (%)

1991 (n = 511) 1996 (n = 540) 18.1 11.9 6.7 2 0.9

Trichomonas vaginalis Chlamydia trachomatis Neisseria gonorrhoeae Syphilis
32

25 20 15 10 5 0

7.5 4.4

Source: UNAIDS 2001.

Comparison of Increase in Condom Use with Decline in Reported Male STIs on a National Scale, Thailand, 19891994
200 65 Male STDS Condom Non-use

Reported Male STDs (in 1000s)

180 160 140 120 100 80 60 40 20 0 1989 1990 1991 1992 1993 1994

45 35 25 15 5 -5

% of Sex Acts Not Protected by Condoms

33

55

Source: UNAIDS 2001.

Ways to Reduce Risk of Transmission

Injection drug use
Offer drug treatment Avoid sharing or reusing needles or other injection equipment or supplies Offer needle exchange programs OR Clean injection equipment with high-level disinfection of needles and syringes by soaking in 0.5% bleach or boiling for 10 minutes Use boiled water to prepare drugs or equipment Clean injection site before injection 34 Safely dispose of syringes after use

Ways to Reduce Risk of Transmission

Traditional Practices
Avoid female circumcision may increase risk of trauma or bleeding with intercourse Do not share sharp instruments used in ritual cutting, tattooing practices OR High-level disinfect instruments after each use

35

MTCT Transmission with Short Course Oral ARV Regimens

Site Regimen ZDV: 36 weeks, labor ZDV: 36 weeks, labor ZDV: 36 weeks, labor, postpartum (mother) Uganda, Tanzania, South Africa ZDV/3TC: 36 weeks, labor, postpartum (mother & newborn) ZDV/3TC: labor, postpartum (mother & newborn) Uganda NVP (single dose): labor, postpartum (newborn) MTCT Reduction

No Breastfeeding
Thailand Breastfeeding Cte dIvoire 37% (3 months) 38% (6 months) 52% (6 weeks) 38% (6 weeks) 47% (4 months)
36

50%

Preventing MTCT in LowResource Settings Breastfeeding

HIV-negative women or women with unknown HIV status
Breastfeed exclusively for 6 months Reinforce use of condoms during breastfeeding

HIV-positive women
Avoid if safe and affordable alternatives available Teach proper attachment of newborn to nipples and frequent breast emptying Seek prompt treatment of mastitis or breast abscess and oral thrush in newborns Breastfeed exclusively for up to 6 months

Photo by: Hugh Rigby, Kenya, 1982

37

Prevention TransfusionRelated
Prevent or treat causes of anemia and blood loss
Malnutrition Malaria Parasitic infestation Pregnancy (repeated pregnancies at short intervals, postpartum hemorrhage)

Minimize unnecessary transfusions: Use blood substitutes (crystalloid /colloid) for volume replacement when possible
38

Prevention TransfusionRelated continued

Select donors carefully: Family replacement and paid or professional donors higher risk Screen blood supply

39

Barriers to Prevention for Women

Stigma of HIV Women often unaware of partners infection status or level of risk Women may be unable to negotiate safer sex practices
Sexual coercion Domestic violence Economic vulnerability

40

Prevention Lessons Learned

Focusing on high-risk groups is not enough Risk behavior and vulnerability should be emphasized Knowledge and awareness are important but not sufficient
Life skills training (sexual negotiation) Condom promotion Long-term change in social norms

41

Prevention Lessons Learned

continued

Socioeconomic interventions to reduce vulnerability are needed

Education of girls Protection of human rights Reduction of stigma

42

Antiretroviral Therapy and Prevention

ARV for HIV-infected persons:
Reduces risk of sexual transmission Reduces incidence of TB Promotes HIV testing

Barriers
Complex regimens Resistance issues Side effects and toxicity Cost
43

HIV Prevention Future Research

Microbicides Postexposure prophylaxis Vaccines

44

References
1.
2. 3.

4.

5. 6.

Anderson J. HIV and reproduction. In Anderson J (ed): A Guide to the Clinical Care of Women with HIV. HRSA/DHHS, 2001. Armed Forces Research Institute of Medical Sciences. Thailand. Chamratrithirong et al. Review of the 100% Condom Programme, Mahidol University. 2001. Compendium of HIV prevention interventions with evidence of effectiveness. Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia. November 1999. Consultation on STD interventions for preventing HIV: What is the evidence? UNAIDS. May 2000. Female condom-guide for planning and programming. UNAIDS. August 2000.

45

References continued
7. HIV prevention needs and successes: a tale of three countries. UNAIDS. May 2001. 8. HIV prevention strategic plan through 2005. Centers for Disease Control and Prevention. January 2001. Institute of Medicine. No time to lose: getting more from HIV prevention. September, 2000 9. Male condom technical update. UNAIDS. September 2000. National STD/AIDS Control Programmes. Senegal and Uganda. 10. Richardson BA, Morrison CS, Sekadde-Kigondu C, et al. Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS 13:2091-7, 1999. 11. Royce RA, Sena A, Cates W Jr, and Cohen MS. Sexual transmission of HIV. N Engl J Med 336:1072-8, 1997. 12. Sex and youth: Contextual factors affecting risk for HIV/AIDS. UNAIDS. May 1999.
46

References continued
13. Sittitrai W, Phanuphak P, Barry J, et al. A survey of Thai sexual behaviour and risk of HIV infection. Int J STD AIDS (England), SepOct 1994, 5(5) p377-8. 14. Sweat M, Gregorich S, Sangiwa G, et al. Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. Lancet 2000;356:113-121. 15. Thongthai et al. Media Effectiveness Survey. Mahidol University. 2001 16. UNICEF, DHS surveys, 1994-1999. 17. The voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. Lancet 2000;356:103-112. 18. Wang C and Celum C. Prevention of HIV. In Anderson JR (ed): A Guide to the Clinical Care of Women with HIV. DHHS, HRSA, HAB. 47 Washington, D.C. 2001.