HIV infected women in Mexico: vulnerability, missed opportunities and late diagnosis MARTIN-ONRAET A. 3, ALVAREZ-WYSSMAN V. 1, VOLKOW- FERNANDEZ P. 3, GONZALEZ-RODRIGUEZ ANDREA 2, VELAZQUEZ-ROSAS G. 4,RIVERA-ABARCA L. 4, TORRES- ESCOBAR INDIANA 5, SIERRA-MADERO J. 1 1 Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 2 Clínica Especializada Condesa, 3 Instituto Nacional de Cancerología, Mexico City, Mexico, 4 Centros Ambulatorios de Prevención y Atención en SIDA e ITS (CAPASITS) Oaxaca, 5 Centros Ambulatorios de Prevención y Atención en SIDA e ITS (CAPASITS) Puebla.

INTRODUCTION HIV in Mexico is a concentrated epidemic driven by infection in MSM Late presentation remains the most important challenge Women represent 20% of affected population Detection campaigns focus on high risk groups that do not include women The only screening strategy for HIV detection in women is pregnancy HIV infected women are particularly vulnerable and represent a double challenge

GOALS What are the sociodemographic and clinical characteristics of Mexican women recently diagnosed with HIV infection? How are women diagnosed with HIV? Are there specific factors reflecting increased vulnerability in women infected with HIV?

STUDY DESIGN AND SAMPLE SUBJECTS: Mexican born HIV-infected women, diagnosed between 2009 and 2013, attending one of 4 HIV care centers of 3 different states: -Oaxaca -Puebla -Mexico City: Instituto de Nutrición and Clínica Condesa DATA: Structured face to face interviews and medical records: -Socio demographics, risk behavior, history of physical/sexual violence, circumstances of HIV diagnosis and access to medical and prenatal care -Clinical information from files Standard statistical analysis was done with Stata 12.0 Ethics approval was obtained, informed consent from women Women were offered legal and psychological counseling

RESULTS

SAMPLE 331 women invited 270 women interviewed 30 did not accept 31 accepted file review 301 women included HIV Care center, n=301N (%) Clínica Condesa94 (31.2) Instituto de Nutrición58 (19.3) Oaxaca100 (33.2) Puebla49 (16.3)

N(%) Indigenous language: - Speaks or understands39 (14) Education: - illiterate23 (7.7) - Primary school (incomplete and complete)70 (23.6) - Secondary school (incomplete and complete)113 (38.1) - High school/commercial career/incomplete degree79 (26.6) - Complete degree12 (4) Participates in household income134 (50.1) Woman as the only provider for their family51 (19.1) Monthly income in USD: - Less than 460 USD222 (94) SOCIODEMOGRAPHIC CHARACTERISTICS 31%

CLINICAL CHARACTERISTICS N (%) Any comorbidity*58 (21) Co-infection HCV/HBV6 (2) History of alcohol abuse33 (11.5) History of illicit substance abuse31 (10.8) Initiation of sexual activity in years, median (range)17 (10-31) Number of pregnancies, median (range)2 (0-13) Number of sexual partners, median (range)2 (1-300) Age at first pregnancy, median (range)20 (12-38) First pregnancy at 18 years or less63 (28.5) Any sexually transmitted disease other than HIV at diagnosis:82 (33.6) - HPV infection 61 (72.6) - Genital herpes 7 (8.3) - Syphilis 5 (6) - Other11 (13.1) *Diabetes Mellitus (5.3%), arterial hypertension (4.4%), dyslipidemia (14.3), others (7.7%)

N(%) History of physical violence at home :126 (47) Who was the aggressor? a - Previous or current partner97 (69.8) - Parents22 (15.8) - brother4 (2.9) - Others16 (11.5) History of sexual abuse:78 (29.7) ¿Who was the aggressor? a - Previous or current partner35 (33.9) - Parents5 (4.9) - brother12 (11.6) - Others51 (47.6) History of imprisonment:11 (4) History of living in the US or the borders16 (6) History of paid sex26 (9.7) VULNERABILITY FACTORS a There might be more than one agressor per woman

Clinical and socio demographic characteristics in different centers CondesaNutriciónOaxacaPueblaP Age at diagnosis <30 yo, n (%)29 (30.8)20 (34.5)48 (48)24 (49)0.04** Speaks or understands indigenous language, n (%)8 (9.6)4 (9.5)25 (25.2)2 (4.2)0.001** Number of sexual partners, median (range)3 (1-300)2 (1-40)2 (1-99)2 (1-45)0.018* History of paid sex, n (%)12 (14.8)1 (2.5)9 (9.3)4 (8.3)NS History of illicit substance use, n(%)16 (18.8)5 (9.4)7 (7.2)3 (6.12)0.04** History of sexual abuse, n (%)32 (39)14 (36)20 (21)12 (25.5)0.04** Baseline CD4 count, median (range) 217 (3-1341) 111 (1-913) 298 ( ) 194 (6-929) <0.001* Reasons for diagnosis, n(%): Recently diagnosed partner or offspring34 (42.5)14 (35)36 (36.3)16 (33.3) Symptoms26 (32.5)19 (47.5)31 (31.3)19 (39.6) Pregnancy8 (10)1 (2.5)16 (16.2)4 (10.9)NS a * Kwallis test, ** χ 2 test a There were statistical differences between INCMNSZ and Oaxaca, for diagnosis through pregnancy (p=0.02)

SOURCE OF HIV INFECTION N(%) Likely source of infection: - Stable partner (current or partner)201 (75) - I don’t know28 (10.5) - Casual partner24 (9) - Other reasons*15 (5.5) Had ever done an HIV test previously65 (24.3) Suspicion of being HIV infected before doing the test62 (23) - Of those who suspected, how many had done a test before29 (46.7) * tatoo (1), rape (5), sharing needles (1), transfusion (5), working accident (3) Reasons to get tested: N(%) Health care provider recommendation175 (65.3) Other reasons a 93 (34.7) a Testing campaigns, donation, prenuptial studies, getting to a lab

CLINICAL STAGE AT PRESENTATION Age at diagnosis, median (range)32 ( ) CD4 count at presentation, median (range)203 (1-1341) CD4<200, n(%)133 (49.3) CD4 <100, n(%)77 (28.5) AIDS defining events at diagnosis, n(%)80 (27.5) Number of AIDS defining events: 111 (there were more than one per patient) Waisting syndrome (48), Cytomegalovirus disease (9), extrapulmonary tuberculosis (9), Candida esophagitis (8), P.jiroveci pneumonia (8), atypical mycobacterial disease (3), pulmonary tuberculosis (5), cryptococosis (3), others (18)

MEDICAL CARE PRIOR TO DIAGNOSIS 68% of women diagnosed through symptoms had sought medical care before * Symptoms such as weight loss, fever, chronic diarrhea, oral candidiasis, herpes

Partner diagnosed (n=83) Child diagnosed (n=11) Symptoms (n=86) Pregnancy (n=20) Others (n=40) Median of CD4 (range) 267 ( )132 (30-659)108 (1-726)322 (6-1138)198 (18-683)

# of medical contactsNone (n=141)1-2 (n=34)3-4 (n=35)5 or more (n=26) Median of CD4 (range)256 (1-1341)217 (7-1138)187 (3-726)31 (10-289)

Characteristics associated to late stage disease at diagnosis (CD4 count <200) Univariate analysisMultiple logistic regression CD4<200CD4>=200OR (CI95%)P P Age at diagnosis: <30 years38 (36.5)66 (63.5)1 1 >= 30 years95 (57.3)71 (42.8)2.32 ( ) ( )0.02 Diagnosis through pregnancy: Yes5 (25)15 (75)1 1 No111 (50.4)109 (49.6)3 ( ) ( )0.2 Number of consultations prior to diagnosis: (39.4)106 (60.6)1 1 3 or more44 (72.1)17 (27.9)3.97 ( )< ( )<0.001 NS: Physical violence, sexual abuse, speaking indigenous language, illegal substance abuse,study degree

PRENATAL CARE

CONCLUSIONS Women recently diagnosed with HIV in Mexico have vulnerability factors such as a high prevalence of physical and sexual violence, low level of education, pregnancies at young age, low incomes and acquiring HIV mainly through their stable partner Women are detected late, except for women diagnosed through pregnancy Most women (73%) are diagnosed because of an infected partner/offspring or being symptomatic Missed opportunities of earlier diagnosis and low rates of HIV testing were detected, during medical and prenatal care

Consequences and perspectives Late diagnosis in women seems to be the result of a deficient health care system and lack of risk perception both from health care workers and women, in a context of high vulnerability and the absence of screening policies for non-pregnant women Strategies for early detection need to be reevaluated for women in countries with concentrated epidemics such as the one in Mexico

ACKNOWLEDGMENTS Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán: –Juan Sierra Madero –María de Lourdes Guerrero Almeida –Juan Calva Mercado –Brenda Crabtree Ramírez –Rigoberto Aramburo García Clínica Especializada Condesa: –Andrea González Rodríguez –Jesús Casillas Rodríguez –Carlos Magis Rodríguez –Florentino Badial Hernández –Ubaldo Ramos Alamillo –Victoria Alvarez Wyssmann –Ricardo Niño Vargas Instituto Nacional de Cancerología: –Patricia Volkow Fernández –Diana Vilar Compte Hospital general Manuel Gea González –Rafael Valdez Vázquez –Patricia Rodriguez Zulueta –Daniel Aguilar Zapata CAPASITS Oaxaca –Gabriela Velázquez Rosas –Lesvia Rivera Abarca –Yuko Nakamura López CAPASITS Puebla –Indiana Torres Escobar –Tayde Pérez reyes