1. Midwest AIDS Training & Education Center Health Care Education & Training, Inc. HIV/AIDS Case-Finding In Family Planning Clinics

2. HIV/AIDS Case-Finding in Family Planning Clinics Section 4: Heterosexual Transmission of HIV

3. HIV/AIDS Case-Finding in Family Planning Clinics Objectives for Section 4 Describe the route of HIV transmission in vaginal sex Identify factors for increased susceptibility Identify factors for increased infectiousness Discuss the risk of HIV infection from anal sex and oral sex Review the differences between contraception and HIV prevention

4. HIV/AIDS Case-Finding in Family Planning Clinics Route of Sexual Transmission

5. HIV/AIDS Case-Finding in Family Planning Clinics Epithelial cells Langerhan’s cells submucosa Mucosal surface lumen Susceptibility STI Hormonal Effects ? Nonoxynol-9 Factors for Increased Susceptibility

6. HIV/AIDS Case-Finding in Family Planning Clinics Epithelial cells Langerhan’s cells submucosa Mucosal surface lumen Factors for Increased Susceptibility

7. HIV/AIDS Case-Finding in Family Planning Clinics Progesterone and Increased Vulnerability to HIV-1 1/10 14/18 Marx, et al. Nature Medicine, 2(10):1084-89, 1996

8. HIV/AIDS Case-Finding in Family Planning Clinics Factors for Increased Susceptibility It is important to discuss factors which may increase HIV susceptibility in your clients: Age STI acquisition Progesterone / Estrogen? Nonoxynol-9?

9. HIV/AIDS Case-Finding in Family Planning Clinics More about Young Women Young women are at an increased risk for HIV infection because: They are biologically vulnerable They are unlikely to be able to negotiate safer sex with an older partner They feel invincible They are more worried about pregnancy than about STIs and HIV

10. HIV/AIDS Case-Finding in Family Planning Clinics Risk of STI Transmission per Episode of Unprotected Vaginal Intercourse %

11. HIV/AIDS Case-Finding in Family Planning Clinics Discussing anal sex with your clients It is imperative that we discuss the risk of STI/HIV transmission from anal sex, regardless of the sexual orientation of our clients, since: Anal sex is prevalent among heterosexuals Anal sex is often used as an alternative to vaginal sex to protect against pregnancy or preserve virginity Effective prevention methods exist for anal sex (condoms, female condoms)

12. HIV/AIDS Case-Finding in Family Planning Clinics Prevalence of anal sex among heterosexuals It is important to discuss the risk from anal sex with female clients: In a study of 1,268 sexually active women, 32% (n=432) reported anal sex in the previous six months (J AIDS, 2000) In a study of men & women aged 13-19, 20% of women and 27% of men reported at least one episode of heterosexual anal intercourse (Moscicki et al., 1993)

13. HIV/AIDS Case-Finding in Family Planning Clinics Discussing oral sex with your clients It is also imperative to discuss the risk of transmission of HIV from oral sex, since: Oral sex is highly prevalent among heterosexuals Oral sex has been shown to have higher rates of transmission than originally proposed Oral sex is often used as a substitute for vaginal and anal sex Effective prevention measures exist (condoms, dental dams, plastic wrap)

14. HIV/AIDS Case-Finding in Family Planning Clinics Clients should be counseled in Risk Reduction Methods Vaginal and anal sex: Condom use Female condom use Abstinence Reduce # of partners Limit the use of substances prior to sexual activity Monogamy Oral sex: Condom use Dental dam or plastic wrap use No brushing or flossing prior to performing oral sex Avoiding ejaculation inside the mouth

15. HIV/AIDS Case-Finding in Family Planning Clinics Clients should be counseled in Risk Reduction Methods Injection Drug Use Needle exchange Cleaning with bleach in absence of new needles No sharing of works Don’t inject (other, less risky routes available) Non-Injection Drugs Reduce intake Don’t combine drugs Choose the least risky route Avoid sexual activity when drunk or high

16. HIV/AIDS Case-Finding in Family Planning Clinics Contraception and Prevention of HIV- 1 Infection (HRSA, 2001) MethodMay Increase Risk No Effect Or Conflicting Data Protective- Strong Evidence Male Condom* Female Condom *

17. HIV/AIDS Case-Finding in Family Planning Clinics Contraception and Prevention of HIV- 1 Infection (HRSA, 2001) MethodMay Increase Risk No Effect Or Conflicting Data Protective- Strong Evidence IUD* Diaphragm* Cervical Cap* Tubal Ligation*

18. HIV/AIDS Case-Finding in Family Planning Clinics Contraception and Prevention of HIV- 1 Infection (HRSA, 2001) MethodMay Increase Risk No Effect Or Conflicting Data Protective- Strong Evidence Vasectomy* Withdrawal* Oral Contraceptives * Depo-Provera*

19. HIV/AIDS Case-Finding in Family Planning Clinics Contraception and Prevention of HIV- 1 Infection The only methods which have strong evidence supporting their efficacy to protect against HIV infection are condoms and female condoms All clients need to be informed of this fact, and counseled in the consistent and correct usage of these methods