HIV is a Preventable Disease

What transformation must be made to prevent it?

Information-->Knowledge-->Getting people to use that knowledge

SPREAD KNOWLEDGE NOT HIV

- There is no magic bullet for prevention

(we can't reverse the epidemic, it's here! We need to reduce the rate of NEW infections)

- Prevention programs need to reach high risk groups

- What behaviors are best targeted?

(partner reduction, condom use, abstinence?)

- Need to sustain prevention gains

Primary prevention

- reduce occurence of disease

- prevent HIV infection among high risk, uninfected groups

Secondary Prevention

- Reduces the progression of the disease

- Reduce HIV transmission by those who are infected

Tertiary Prevention

- Reduces or limits the disability from the disease

Primary prevention

- modifying risky behaviors-->don't do it!

- At the beginning it seemed to be helping

- Now-->new infections on the rise

In the US in 1988 new infections dropped by 40,000/year

Between 2002-2008 new infections increased to 56,000/year

Only 1/3 of adults with 3 or more partners have been tested for HIV in the past 18 months

of 4000 HIV+ patients,

Les than 20% of partners have been notified

Less than 5% of partners have been tested

Studies show that that risky behavior decreased by 1/2 in those who are HIV+

- The CDC in conjunction with the Dept. of Health and Human services decided to changed to a secondary prevention strategy (prevent transmission by those who are infected)

- This will require $15 billion over the next 10 yrs

- It is unknown if countries will adopt the US strategy

- Strong leadership

- Quality science and surveillance

- Consider local society and culture

- Include all sectors of the population

- Eliminate stigma and discrimination

- Eliminate gender inequality

Education!

Programs need to target school-age youth

Today's 6th graders are hearing less about HIV that those in the 1990s

What are the:

- Highest Risk

- Risky

- Less Risky

- Low Risk

- Very Low Risk

- Absolutely Safe

sexual practices realting to the transmission of HIV?

- Highest Risk: receptive anal intercourse, injection drug use

- Risky: Insertive anal sex, vaginal sex

- Less Risky: oral sex

- Low Risk: rimming, fisting

- Very Low Risk: mutual masturbation, shared sex toys, deep kissing

- Absolutely Safe: self masturbation, abstinence  

- Prevention of sexual transmission of HIV

- Prevention of mother-to-child transmission

- Prevention of HIV transmitted through the blood

- intravenous drug users

- transfusions and blood products

- health care professionals

What is the ABC (adopted by Botswana in the 1990s) approach to AIDS prevention?

Abstain

Be Faithful

Condomise

- Abstinence or delaying first sex

- Be faithful to one partner or by reducing the number of sexual partners

- Correct and consistent use of condoms for sexually active young people, couples in which one partner is HIV-positive, sex workers/clients, and anyone engaging om sexual activity with partners who may have been at risk of HIV exposure

Condoms

How long are they traced back and how many folds do they prevent transmission by?

They trace back to 1000 B.C.  (more often used to prevent STDs, not pregnacy)

- 5 fold reduction for vaginal intercourse

- 3 fold reduction for anal intercourse

What are the moral objections surrounding condoms?

- Condom distribution leads to more sex

- Catholic church is instrumental in AIDS health care

- In 2006, pope Benedict asked his health council to investigate condoms for married couples where one is HIV+

- They believe that if you need a condom, you must be doing something immoral

Men are more dominant in many cultures

American young men are embarrassed to use/buy condoms

- In the US in 1985, women bought 10% of all condoms and now it is 50-60%

- Safe sex is a plot to reduce pleasure

- HIV negative men intentionally trying to become HIV+

- When asked, they think of AIDs as a minor annoyance that can be treated

new definition resulting from linkage:

sex=intercourse

both conservatives and liberals agree

sex=reproduction

What has the role of education been?

Who is Sylvia Hacker?

Teach alternatives to intercourse

Hacker wrote a commentary on "outercourse"

Birth control may have led to its loss in the culture

In SF, gay male transmission is down from 10-20% a year to 1% a year

Failures to address the coming generation

Educators tried

AIDS now longer new

- Polyurethane for those allergic to latex

- Female condom

- Substances that can prevent HIV from spreading

• Bi directional woulod be best, capable of disabling HIV in both semen and vaginal secretions

- Vaginal and rectal forms

- Would give women more control

- First generation may not be approved by FDA until 2012 (10 failed trails to date)

Issues: can't impair ability to conceive, no damage to sperm, no other side-effects

- condoms still more effective

- can be a risky procedure

- overconfidence leads to risk taking

- not acceptable in all cultures

- no protection for women

- a single dose drug (nevirapine) during labor and to the baby after delivery decreased rate of transmission

(cheap and easy, extreme drug resistance and should be used only when no other choice)

- Combining drugs

(start drugs after 28 weeks, baby and mother should take them for 7 days after birth)

- HIV counseling

- Encourage HIV test as a part of routine check-up

- Mothers are adivsed not to breast-feed

- Infectivity of HIV related to dose

- THe more washback, the more infection

- Not the 1/300 needle pricks

- Especially during silent phase

- In US, about 50% of all new HIV infections occur from IDU

- 50% of IDU share equipment

- population isolated from education

- connection with prostitution

- only source of money

- Criminal activity

- no spokespersons or focus groups

- immedicay of need for drugs vs planning for safe needles

- general poor health and nutrition

- little interest in chaning their behavior

1 clean needle/syringe for 1 used

- also provide educational material and testing

By 2008, 50 US states had NEPS (however, there is no funding provided by the federal government)

Worldwide, 77 countries have NEPS

YES!

 and they do not increase drug use!

NY study between 1999-2001 among IDUS found that HIV prevalence fell from 54%-13% following introduction of NEPS

Once a major route of transmission

- A large dose of HIV blood is almost certain to result in HIV infection

- A small dose (needleprick) seldom results in infection (1/300)

In developing countries, 10% of all new HIV infections are from tainted blood

In US, chances are 1 in a million

In 2002, 3 people became HIV infected from blood transfusion in florida (traced back to donor in window period)

When possible, autologous blood transfusions

52 medically related restrictions for donated blood

1. The blood and certain body fluids of ALL patients are considered infectious

2. Wash hands and any skin in contact with body fluids

3. Use protective barriers

4. Cover cuts with bandages

5. Handle needles with care and dispose of properly (use only once!)

Anti-HIV drugs are given soon after injury

Reduces rates of transmission

- break the chain of transmission

- treat or counsel partners

- prevent guilt of innocent transmission

- it it that right of the uninfected to remain so

in early 1990s, 15% of adults living with HIV

in 2001, 5% of adults living with HIV

Attributed to strong political leadership, open communcation, grassroots organizations, condom distribution, HIV testing, and treatment of sexually transmitted infections

Prevalence remains at .5%

Explicit media campaigns for condom use (74% of sex workers use them consistently)

Needle distribution ( 75% of IDUs reported no needle sharing)

- Prisoners get access to needles and condoms

- 58% of HIV+ women have access to drugs to prevent mother-to-child prevention

1. Threat of discrimination

2. Will it change any behavior?

3. No cure

- Helps with mother-to-child transmission

- post exposure prophylaxis (needle sticks)

- keeps viral loads low, less chance an HIV+ person can spread it

- Increases HIV testing--now people have a reason to be tested

- Increases risky behaviors

- People live longer, increases chance to spread it

- .1% prevalence

- 1986 had routine screening

- Initially, indefinite quarantine. In 1993 allow a choice

- Good medical care

- Data base of all HIV+ and partner

- Mother-to-child almost unheard of

Success story in Thailand

- Condom distribution to sex workers (clamp down on those who fail to use them)

- Rights of women promoted

- Anti-AIDS messages broadcast

- 1991, annaul diagnosis: 143,000

2003, annual diagnosis: 19,000

- open communication

- combated stigma and discrimination

- people will continue their behavior, lets help them do it more safely

- community involvement: done with them, not to them

Are countries still successful with AIDs prevention?

- In all countries, a small, but significant rise in new HIV infections (but the numbers are still good!)

Why?

- Better treatments, so less worry?

- Fatigue in keeping up with the prevention campaigns