1. HIV Screening and Women’s Health Health Care Education & Training, Inc. Originally developed by: Section 1: Why Test All Our Clients?

2. 2 2 2007 Contributors from AETC Women’s Health and Wellness Workgroup:  Laura Armas, MD; Texas/Oklahoma AETC  Suzanne Carlberg-Racich, MSPH; Midwest ATEC (MATEC)  Monique M. Clesi; Planned Parenthood of Indiana  Andrea Norberg, MS, RN; AETC National Resource Center  Tonia Poteat, MPH, MMSc, PA-C; Southeast ATEC (SEATEC)  Barbara Schechtman, MPH; Midwest ATEC (MATEC)  Karen Sherman, MA; Health Care Education and Training, Inc.  Jamie Steiger, MPH; AETC National Resource Center The original curriculum was developed in 2002 by MATEC and Health Care Education & Training, Inc. HIV Screening and Women’s Health

3. 3 3 Objectives for Section 1: 1.Identify four reasons to test family planning clients 2.Explain what puts women at risk for HIV infection 3.Understand the impact of hormone-based birth control on HIV risk 4.Describe missed opportunities for HIV testing in healthcare settings 5.List ways that early identification can improve HIV disease outcomes HIV Screening and Women’s Health

4. 4 4

5. 5 5 There are (at least) 4 reasons for testing all of our clients 1.Women who get services in family planning clinics are at risk for getting HIV 2.There are too many missed opportunities for clients to understand their HIV status 3.Knowing your status is good for your health 4.Testing and clinical identification can be integrated into current family planning services, and who else could do this better and with more sensitivity? HIV Screening and Women’s Health

6. 6 6 Reason 1 Women who get services in family planning clinics are at risk for getting HIV HIV Screening and Women’s Health

7. 7 7 Why are women in family planning clinics at risk? Because women are at risk HIV Screening and Women’s Health

8. 8 8

9. 9 9 Why are women in family planning clinics at risk? Because young women are at risk and they represent a large proportion of family planning clinic clients HIV Screening and Women’s Health

10. 10 Reproductive Health and HIV Are Adolescents and Teens at Risk? Over half of all HIV infections in the U.S. occur in people under the age of 25! HIV Screening and Women’s Health

11. 11 HIV Screening and Women’s Health

12. 12 HIV Screening and Women’s Health

13. 13 Why are women in family planning clinics at risk? Because of their sexual partner HIV Screening and Women’s Health

14. 14 HIV Screening and Women’s Health

15. 15 So, what does put women at risk? For well over half (71%) of women, the answer is clear: SEX WITH MEN That is why it is important to explain HIV transmission to women and to make sure all women know their HIV status. HIV Screening and Women’s Health

16. 16 U.S. Women and Risk  Women are > 2 times as likely to be infected by a husband or steady partner than a casual partner  Along with injection drug use, unsafe sex with other men appears to be a significant risk factor for some women because of the risks taken by the male partner (McMahon et al., 2004) HIV Screening and Women’s Health

17. 17 U.S. Women and Risk (continued)  Among men who have sex with men, 9% of the men reported also having female sex partners (Harawa et al., 2004)  Among young African American men who have sex with men, 20% of the men reported also having female sex partners (CDC, 2004) HIV Screening and Women’s Health

18. 18 Why are women in family planning clinics at risk? They may be at an increased risk, due to hormone use, sexual activity, or sexually transmitted infections (STIs) HIV Screening and Women’s Health

19. 19 Progesterone and Increased Vulnerability to HIV-1 HIV Screening and Women’s Health (Marx et al., 1996)

20. 20 Hormones and HIV  Women using Depo-Provera or oral contraceptives were twice as likely to become infected with HIV than those not using these methods (Baeten et al., 2003)  CCR5 receptor density within cells is influenced by progesterone (Prakash et al., 2004 and Patterson et al., 1998) HIV Screening and Women’s Health

21. 21 Hormones and HIV (continued)  Women using oral contraceptives while already HIV positive may be more infectious to their partners than those not using oral contraceptives (Prakash et al., 2004) Reproductive Health and HIVHIV Screening and Women’s Health

22. 22 Integrity of the Mucosal Barriers  Increased risk of HIV transmission  Cut  Sore  Ulcer  Microscopic abrasions  STIs  Traumatic sex HIV Screening and Women’s Health

23. 23 Type of Sexual Activity  32% of sexually active women report having anal sex (Gross et al., 2000)  20% of females ages 13-19 and 27% of males 13-19 reported at least one episode of heterosexual anal intercourse (Moscicki et al., 1993) HIV Screening and Women’s Health

24. 24 Risk of STI Transmission per Episode of Unprotected Vaginal Intercourse HIV Screening and Women’s Health (Alan Guttmacher Institute, 1996)

25. 25 Reason 2 There are too many missed opportunities for clients to understand their HIV status. HIV Screening and Women’s Health

26. 26 HIV Screening and Women’s Health

27. 27 HIV Screening and Women’s Health

28. 28 HIV Screening and Women’s Health

29. 29 HIV Screening and Women’s Health

30. 30 Healthcare Providers Diagnosing HIV Infection Reproductive Health and HIVHIV Screening and Women’s Health (MacDonald et al., 1998)

31. 31 More evidence of missed opportunities…  For clients without HIV-related diagnoses at previous medical visits, it took a median 2.5 years for diagnosis to occur in a study in South Carolina (MMWR, 2006)  Even for clients with “HIV triggers,” there were an average of 5 medical visits to one institution before being diagnosed with HIV (Liddicoat et al., 2004) HIV Screening and Women’s Health

32. 32 Role of Reproductive Healthcare Practitioners in Diagnosing HIV Reproductive Health and HIV PACTG 367 n=1,527 pregnancies Timing of HIV Diagnosis HIV Screening and Women’s Health

33. 33 Who Initiates Testing? Reproductive Health and HIV In one study …. In this study by MacDonald and colleagues (1998), eight providers denied testing to women who specifically asked to be tested HIV Screening and Women’s Health

34. 34 Definition of “Missed Opportunity” An encounter with a healthcare provider for any reproductive health issue—regardless of risk factors or any contact with any other healthcare provider—by a client engaging in high risk behavior where testing was not performed HIV Screening and Women’s Health

35. 35 Key Findings in the MacDonald Study  73 of 81 women had had 116 health care encounters  75% of those encounters were missed opportunities for HIV screening  80% of the women had at least one missed opportunity in 12 months before diagnosis  78% had missed opportunities at reproductive health encounters HIV Screening and Women’s Health

36. 36 Avoiding Missed Opportunities HIV Screening and Women’s Health  To avoid any missed opportunities, the family planning clinic should: Offer HIV testing to all women using clinic services Perform risk reduction counseling with all clients when offering the test Encourage retesting as needed, as a positive step in managing one’s health

37. 37 Reason 3 Knowing your status is good for your health HIV Screening and Women’s Health

38. 38 Health Benefits of Knowing Your HIV Status HIV Screening and Women’s Health  Effective treatment is available  Treatment is more beneficial before the disease has progressed  Opportunity to prevent transmission to infants  Opportunity to prevent transmission to sex partners  If you are negative, actions can be taken to stay negative.

39. 39 Reason 4 Testing and clinical identification can be integrated into current family planning services, and who else could do this better and with more sensitivity? HIV Screening and Women’s Health

40. 40 Why reproductive health clinics?  You see women at risk  You already know how to talk openly about sexual activity with clients  They trust you! HIV Screening and Women’s Health

41. 41 Recommendations For Routine Screening  Screening should be performed routinely, along with other family planning services  Screening should also be performed in response to risk factors, with retesting as needed and agreed to by the client HIV Screening and Women’s Health

42. 42 HIV Screening and Women’s Health

43. 43 Resources  AIDS Education and Training Centers www.aidsetc.org www.aidsetc.org  Title X Family Planning Regional Training Centers http://opa.osophs.dhhs.gov/titlex/ofp-training-grantees- listing.html http://opa.osophs.dhhs.gov/titlex/ofp-training-grantees- listing.html  Centers for Disease Control and Prevention http://www.cdc.gov/hiv/topics/testing/index.htm  National HIV/AIDS Clinicians’ Consultation Center http://www.ucsf.edu/hivcntr/  Family Health International  Establishing Referral Networks for Comprehensive HIV Care in Low-Resource Settings http://www.synergyaids.com/documents/RefNetsGuide2.pdf http://www.synergyaids.com/documents/RefNetsGuide2.pdf HIV Screening and Women’s Health

44. 44 References Alan Guttmacher Institute. (1994). Sex and America's Teenagers (Report), New York, NY: Alan Guttmacher Institute. Anderson, J.R., ed. (2005). A Guide to the Clinical Care of Women with HIV. Health Resources and Services Administration HIV/AIDS Bureau. Baeten, J.M. et al. (2003), Measuring the Infectiousness of Persons with HIV-1: Opportunities for Preventing Sexual HIV-1 Transmission, Current HIV Research, 1(1), 69-89. Baeten, J.M., Nyange, P.M., Richardson, B.A., Lavrevs, L., Chohan, B., Martin, H.L., Madaliva, K., Ndinva-Achola, J.O., Bwayo, J.J., & Kreiss, J.K. (2001). Hormonal contraception and risk of sexually transmitted disease acquisition: results from a prospective study. American Journal of Obstetrics and Gynecology, 185(2):380-5. Branson, B.M. Revised Recommendations for HIV Testing in the Healthcare Setting in the U.S. Retrieved on November 1, 2007 from http://www.cdc.gov/hiv/topics/testing/resources/slidesets/pdf/testing_healthcare.pdf Centers for Disease Control and Prevention. HIV/AIDS Surveillance in Adolescents and Young Adults (through 2005). Retrieved on November 1, 2007 from http://www.cdc.gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm Centers for Disease Control and Prevention. HIV/AIDS Surveillance in Women. Retrieved on November 1, 2007 from http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/index.htm Centers for Disease Control and Prevention. (2004), HIV transmission among black college student and non-college student men who have sex with men – North Carolina, 2003, MMWR, 53, 731-734. Centers for Disease Control and Prevention (2006), Missed Opportunities for Earlier Diagnosis of HIV Infection --- South Carolina, 1997-2005, MMWR, 55 (47); 1269-1272. HIV Screening and Women’s Health

45. 45 References (continued) Gross, et al. (2000). Anal sex among HIV-seronegative women at high risk of HIV exposure. The HIVNET Vaccine Preparedness Study 2 Protocol Team. Journal of AIDS, 24(4), 393-398. Harawa, N.T., Greenland, S., Bingham, T.A., Johnson, D.F., Cochran, S.D., Cunningham, W.E., Celentano, D.D., Koblin, B.A., LaLota, M., MacKellar, D.A., McFarland, W., Shehan, D., Stoyanoff, S., Thiede, H., Torian, L., & Valleroy, L.A. Associations of race/ethnicity with HIV prevalence and HIV-related behaviors among young men who have sex with men in 7 urban centers in the United States. (2004). Journal of Acquired Immune Deficiency Syndromes, 35(5):526-36, Liddicoat, et al. (2004). Assessing Missed Opportunities for HIV Testing in Medical Settings. J Gen Intern Med, 19: 349-356. MacDonald, S.R., Skor, A., Socol, M.L., & Garcia, P.M. (1998). Human immunodeficiency virus infection and women: a survey of missed opportunities for testing and diagnosis. American Journal of Obstetrics and Gynecology, 178(6):1264-71. Marx, P.A., Spira, A.I., Gettie, A., Dailey, P.J., Veazey, R.S., Lackner, A.A., Mahoney, C.J., Miller, C.J., Claypool, L.E., Ho, D.D., & Alexander, N.J. (1996). Progesterone implants enhance SIV vaginal transmission and early virus load. Nature Medicine, 2(10): 1084-9. McMahon et al. (2004). Increased sexual risk behavior and high HIV seroincidence among drug- using low-income women with primary heterosexual partners. Int Conf AIDS. Jul 11-16; 15: abstract no. TuOrD1220. Moscicki, A.B., Millstein, S.G., Broering, J., & Irwin, C.E. (1993). Risks of human immunodeficiency virus infection among adolescents attending three diverse clinics. Journal of Pediatrics, 122 (5 Pt 1): 813-20. HIV Screening and Women’s Health

46. 46 References (continued) Padian, N.S., Shiboski, S.C., Glass, S.O., & Vittinghoff, E. (1997) Heterosexual transmission of human immunodeficiency virus (HIV) in northern California: results from a ten-year study. Am J Epidemiol 146: 350-7 Patterson, et al. (1998). Repertoire of chomokine receptor expression in the female genital tract: Implications for human immunodeficiency virus infection. American Journal of Pathology, 153, 481-490. Prakash, et al. (2002). Oral contraceptive use induces upregulation of the CCR5 chemokine receptor on CD4+ T cells in the cervical epithelium of healthy women. Journal of Reproductive Immunology, 54(1-2), 117-131 Prakash, M., Patterson, S., Gotch, F., & Kapembwa, M.S. (2004). Ex vivo analysis of HIV-1 co-receptors at the endocervical mucosa of women using oral contraceptives. British Journal of Obstetrics and Gynecology, 111: 1468-1470. Shapiro D, Tuomala R, Samuelson R, et al. Mother to child HIV transmission rates according to antiretroviral therapy, mode of delivery and viral load (PACTG 367). Program and abstracts of the 9th Conference on Retroviruses and Opportunistic Infections; February 24-28, 2002; Seattle, Washington. Abstract 114. Valleroy et al. (2004). The bridge for HIV transmission to women from 15- to 29-year- old men who have sex with men in 7 US cities. Int Conf AIDS. Jul 11-16; 15: abstract no. ThOrC1367. HIV Screening and Women’s Health