1. Ten Most Wanted: 28 th November 2011 Item Code: UK/MEDed/2011/0269a Date of Prep: November 2011

2. HPA Data Slide Women 1

3. Case Study – Ms A 30 year old woman from Nigeria Eldest of 5 children, parents in Lagos Arrived in London as a student in 2008 Lives with a Nigerian partner of 3 years and 6 yr old daughter from a previous relationship Student visa expired 6 months ago: overstayer Member of Pentecostal church. Women 2

4. Ms A Pregnant: Positive HIV antibody test in antenatal screening. PMH : hospitalisation for pneumonia Baseline investigations – Viral load 105,000 copies/mL – Clade AG, wild type – CD4 count 180 cells/mm 3 – Hepatitis B immune; Hepatitis C negative. Women 3

5. Ms A Shocked and very upset Cannot accept that she is the sort of person to be at risk Insists no one should be told HIV diagnosis Fears the reaction of her partner Declines peer support. Women 4

6. Key Management Points Antiretroviral therapy: what to start Disclosure to partner Testing of partner Testing of child Entitlement to health and social care. Women 5

7. Women Coping With HIV in the UK 1.Anderson J, Doyal L.AIDS Care 2004;16:95-105; 2.Doyal L, Anderson J. Soc Sci Med 2005;60:1729–38. Healthcare providers Peer support Information management (keeping secrets) Faith and spirituality APPROACH TO TREATMENT SUPPORT AND CARE DISCLOSURE Women 6

8. Ms A Ms A and her doctor discuss – Her recent results – Benefits of ART…. – Potential drug regimens. During ART discussions A tells her physician about her belief in God as a ‘healer of all’ – Questions the need for any medication – Discusses the role of prayer. Women 7

9. ART for the Long Term: What to Start Considerations when prescribing for women – Efficacy, toxicity, adherence Backbone – Zidovudine vs Tenofovir vs Abacavir Third agent – Nevirapine vs Atazanavir vs Lopinavir Women 8

10. Antiretroviral Therapy for Women Lack of woman specific data Inadequate numbers of women enrolled in clinical trials Sex based analysis lacking Observational and cohort studies predominate Extrapolation of male data to a female population. d’Arminio Monforte et al., AIDS 2010 24:1091–1094. Women 9

11. Progress After considerable discussion A takes advice to start therapy – 18/40 Initiate Truvada + Atazanavir/r Adherence excellent “Textbook” virological response - with undetectable viral load by 30/40 V/L remains suppressed throughout the remainder of her pregnancy. Women 10

12. Disclosure Anna is terrified of telling her partner that she has HIV – She is unsure about her partner’s serostatus This prompted a discussion about disclosure with her doctor... Women 11

13. Kapp C, Lancet 2009; 373: 2106 Women 12

14. Advantages of disclosure include 1 – Acquisition of social support – Relief from sharing a secret – Ability to educate others – No need to hide treatment and adherence rituals – Improved access to HIV prevention and treatment services. 2 Perceived risks of disclosure include 1 – Stigmatism for self and family – Fear of isolation and possibly discrimination at work – Fear of violence – Provoke feelings of anxiety – Fear of associated financial costs. Women Living with HIV and Disclosure 1.Serovich JM, et al. AIDS Behav 2008;12:227–31; 2.Elford J, et al. JAIDS 2008;47:514–21. Women 13

15. Testing Children A is very worried about testing her 6 year old daughter Referred to a paediatric Clinical Nurse Specialist for advice and support – Her daughter is tested and is HIV negative. Peer support for women with HIV A finally agrees to meet another woman living with HIV Will only accept a meeting in the clinical space Positively UK peer support scheme for pregnant women. Women 14

16. At 36 Weeks A has still not told anyone outside the clinical team about her HIV infection Partner remains unaware Mother due to arrive imminently from Lagos to help with the new baby A tells you that she cannot bottle feed her baby and wishes to breastfeed. Message in a Bottle “Good” mothers breast feed their babies Family members expect women to breastfeed Replacement feeding strongly associated with HIV HIV associated stigma remains a huge issue across the world - even where replacement feeding is theoretically “safe” Resource rich countries and access to replacement feeding. Women 15

17. UK Infant Feeding Advice Recommend & provide full support for replacement feeding If a woman has a compelling reason to breastfeed – Effective HAART with undetectable viral load – Breastfeed for as short a time as possible – Monitor both mother and baby for toxicity – Wait at least a week after stopping breastfeeding before withdrawing HAART – Risk to the baby is likely to be very low – In such circumstances no longer a matter for child protection. Taylor G, Anderson J, Clayden P, Gazzard B, Fortin J, Kennedy J, et al.HIV Med. 2011 Aug;12(7):389-93. Women 16

18. Ms. A 2-Months Post Partum A tells her partner about her HIV diagnosis He gets tested for HIV – His test results show he is HIV positive He becomes is increasingly withdrawn and one week later walks out without warning. Women 17

19. The hierarchy of human need Adapted from Maslow’s Hierarchy of Needs. Available at: http://honolulu.hawaii.edu Accessed 05 October 2009. Priorities Women 18

20. “The third epidemic, of social, cultural, economic and political reaction to AIDS....is as central to the global AIDS challenge as the disease itself. ” Jonathan Mann 1987. Women 19