1. 7/2004 D. Loeb-Guth, Delta Region AETC Not Another……Prevention for Positives Talk!!!! Desiree Loeb-Guth RN, MPH State Training Coordinator Delta Region AIDS Education and Training Center

2. 7/2004 D. Loeb-Guth, Delta Region AETC Incorporating HIV Prevention into the Medical Care of Persons Living with HIV MMWR from July 18, 2003 Recommendations of CDC,HRSA, NIH, and the HIV Medicine Association of the Infectious Disease Society of America

3. 7/2004 D. Loeb-Guth, Delta Region AETC Program Objectives Understand the CDC-identified methods for provision of prevention services in HIV medical settings Gain knowledge of strategies to discuss HIV high risk behaviors with patients. Review cases on prevention practice in HIV clinical settings

4. 7/2004 D. Loeb-Guth, Delta Region AETC Guidelines for Incorporating HIV Prevention and Care Recommendations 1.Screen all HIV positive persons for risk behaviors associated with HIV transmission STDs and pregnancy

5. 7/2004 D. Loeb-Guth, Delta Region AETC Guidelines for Incorporating HIV Prevention and Care Recommendations 2)Provide brief interventions for behavioral risk reduction in the clinic setting Refer patients to appropriate additional interventions and services

6. 7/2004 D. Loeb-Guth, Delta Region AETC Guidelines for Incorporating HIV Prevention and Care Recommendations 3)Facilitate notification and counseling of sex and needle sharing partners of persons living with HIV/AIDS

7. 7/2004 D. Loeb-Guth, Delta Region AETC Step 1 Behavioral Risk Screening Screening should be brief Possibly a questionnaire, computer assisted, during the medical encounter or before. If self administered, the clinician can review results when seeing patient Use of posters, pocket cards, forms or reminders can help facilitate this screening

8. 7/2004 D. Loeb-Guth, Delta Region AETC Louisiana Office of Public Health

9. 7/2004 D. Loeb-Guth, Delta Region AETC STD Assessment Presence of STD causes a 5-fold increase in transmission risk Clinicians should routinely ask about STD symptoms Screening asymptomatic patients about STDs should be conducted yearly Screen for syphilis at the initial visit Screen women for chlamydia Screen for pregnancy when needed

10. 7/2004 D. Loeb-Guth, Delta Region AETC When to STD Screen? CDC states that STD screening should be done based on epidemiological data and cost effectiveness factors The easiest test is the NAAT for chlamydia and gonorrhea Screen annually if patient is sexually active Screen more often for asymptomatic persons at higher risk

11. 7/2004 D. Loeb-Guth, Delta Region AETC Step 2 Provide Brief Interventions for Behavioral Risk Reduction Risk assessment Risk reduction counseling Referral as needed for additional interventions and services

12. 7/2004 D. Loeb-Guth, Delta Region AETC Why Add Something Else for Clinicians to Address? 350,000-520,000 patients make use of the clinical setting for their HIV care each year. RW Care Act providers have an on-going trusted relationship with their patients and are in a unique position to provide risk reduction and prevention services. If made routine it will take less time. Make it an integral part of the whole clinic function.

13. 7/2004 D. Loeb-Guth, Delta Region AETC Step 3 Facilitating Notification and Counseling of Partners Partner Counseling and Referral Services (PCRS) Confidentially informs partners of exposure Advises them to have C and T In La. the local DIS Specialist can be notified.

14. 7/2004 D. Loeb-Guth, Delta Region AETC HIV Serostatus Disclosure Majority of patients disclose to main partners (74%) and family members (69.8%) Adolescents tend to disclose less Lower CD4 counts are associated with disclosure Less than ¼ disclosed to casual sex partner (24.8%) Prevalence and Correlates of HIV Serostatus Disclosure, M. O’Brien et al, J. American Sexually Transmitted Disease Association. May 2003

15. 7/2004 D. Loeb-Guth, Delta Region AETC DIS Directory Region I- 504-568-7700 Region II- 225-342-1799 Region III-985-447-0916 Region IV- 337-262-5616 Region V- 337-480-2608 Region VI- 318-487-5338 Region VII- 318-676-5403

16. 7/2004 D. Loeb-Guth, Delta Region AETC DIS Directory Region VIII- 318-361-7223 Region IX- 985-871-1284

17. 7/2004 D. Loeb-Guth, Delta Region AETC 60-second Sexual History Is it OK to talk about sex right now? Could you tell me a bit about your sex life? When was the last time? (men/women/both) How many partners in the last 2 years? Oral/anal/vaginal? Know how you might have been infected? Use of condoms? Sex while drinking/drugging? Previous STD?

18. 7/2004 D. Loeb-Guth, Delta Region AETC Examples of Other Risk Screening Questions Open ended questions: –How do you think you might have transmitted HIV to a partner? –Tell me about your sex life lately –Tell me about how you may have been re- infected with HIV through sex or drug use. –Since you found out about being HIV positive, have you had oral, anal or vaginal sex? –Tell me about your condom use

19. 7/2004 D. Loeb-Guth, Delta Region AETC More Screening Questions Have you had vaginal or anal sex without a condom? Have you had oral sex? Did fluid get into your mouth or the other person’s mouth? Have you noticed any sores, burning, discharge or itching? Have you shared needles or (syringes, cooker, water) nasal straws with anyone? Have you discussed HIV with your partner(s)?

20. 7/2004 D. Loeb-Guth, Delta Region AETC Risk Screening Strategies Remember to build rapport Discuss risk from the first visit and every subsequent visit Use a non-judgmental, empathic, comfortable counseling voice Choose language that is easy to understand and non offensive Ask to discuss risk behavior/explain why

21. 7/2004 D. Loeb-Guth, Delta Region AETC Laboratory Screening for STDs (conduct at baseline and at least every year for patients who have sex) Syphilis- VDRL or RPR Gonorrhea and Chlamydia-urethral (men) Cervical (women) or NAAT (first catch urine) Women-Trich wet mount (Cervical) Men having receptive anal Sex-GC and Chlam swab culture

22. 7/2004 D. Loeb-Guth, Delta Region AETC Risks for Conducting More Frequent STD Testing Multiple or anonymous sex partners Past history of any STD Identification of high risk behaviors Sex or needle sharing partners with the above risks Life changes that lead to increased risk behavior High prevalence of STDs in the population

23. 7/2004 D. Loeb-Guth, Delta Region AETC HSV-2 Herpes Simplex Virus is prevalent among HIV-infected persons and might increase the risk of transmitting and acquiring HIV. Persons with HSV-2 should be counseled about this increased risk and about recognition of symptoms.

24. 7/2004 D. Loeb-Guth, Delta Region AETC Behavioral Interventions Strategies to reduce risk or harm These should be tailored to the patient’s language, culture, sex, sexual orientation, age and developmental level. HIV prevention messages should be delivered at a minimum of twice yearly.

25. 7/2004 D. Loeb-Guth, Delta Region AETC Basic Prevention Messages Explain the risk for HIV transmission with specific sexual behaviors Explain the effect of viral load on HIV transmissibility Ascertain correct use of condoms Explain the relationship between STDs and HIV

26. 7/2004 D. Loeb-Guth, Delta Region AETC Estimated Relative Risk of Acquiring HIV Based on Sex Act and Condom Use Insertive fellatio1 Receptive fellatio2 Insertive vaginal10 Receptive vaginal20 Insertive anal13 Receptive anal100 *********************************************** Condom use -yes1 Condom use -no20 See MMWR, July 18, 2003 Table 5

27. 7/2004 D. Loeb-Guth, Delta Region AETC Ratios of Risk for Transmission and Acquisition of HIV Among Discordant Couples <3,500Referent 3500-99995.8 10,000-49,9996.91 >50,00011.87 Per log increment in VL= 2.45 See MMWR, July 18, 2004, page 10, Table 6.

28. 7/2004 D. Loeb-Guth, Delta Region AETC Clinician Training Develop strategies for incorporating risk reduction interventions into patient clinic visits Obtain training on speaking with patients about sex and drug use behaviors and giving explanations in simple everyday language Become familiar with interventions that work

29. 7/2004 D. Loeb-Guth, Delta Region AETC What Are the Variables that Predict Whether a Clinician will Discuss Safer Sex and Needle Use? Positive OB/GYN Female clinician Low income, low ed. population Preventing HIV transmission from HIV Positive to HIV- Negative individuals, Donald Graves, MD Negative Family Practice/GP Feeling that patient may get offended Time pressures Lack of confidence Ethics of reporting Communication barriers

30. 7/2004 D. Loeb-Guth, Delta Region AETC What are Variables that Increase High Risk Behavior? Substance Abuse (Heroin, Speed, Ex, GHB, Viagra) Fatigue of using barrier Attempts to enhance intimacy Poor understanding of transmission Gender inequalities Optimism about ART effectiveness

31. 7/2004 D. Loeb-Guth, Delta Region AETC Referrals for Additional Prevention Interventions IDU-treatment, methods to sustain drug abstinence, referral to obtain clean needles Sexual risk-CBOs, G-L community centers, Planned Parenthood, Behavioral Psychologists, Health Educators HIV Clinician Resources Guide 2003-2004 Call 504-903-0788 to obtain

32. 7/2004 D. Loeb-Guth, Delta Region AETC Case 1 A newly diagnosed patient comes to your clinic for an initial visit. Of the many things that must be addressed (emergent medical, psychiatric, history, physical, labs, etc.) you want to address prevention. What is the minimum that can be done and how can it be incorporated into the visit?

33. 7/2004 D. Loeb-Guth, Delta Region AETC Case 1- Prevention How acquired, assess risk behaviors, current partners and whether tested Genital and rectal exam and tests for STDs Provide risk reduction recommendations, (sex and IDU) Discuss disclosure to partners and possible barriers to disclosure Follow-up above in each subsequent visit.

34. 7/2004 D. Loeb-Guth, Delta Region AETC Case 2 A patient with chronic stable HIV comes to you with a new STD. What prevention considerations should be covered in this visit?

35. 7/2004 D. Loeb-Guth, Delta Region AETC Case 2- Prevention Discuss partners, number of episodes and types of unsafe sex Discuss personal risks associated with high risk behavior Assess whether high risk is related to social problems and if adherence is also affected. Genital exam with testing for other STDs Discuss partner notification and treatment Document for on-going, intensive follow-up