1. 1 HIV Prevention for Patients and the Community HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 2 Learning Objectives By the end of this session, participants should be able to: Describe three main routes of HIV transmission Explain factors that both increase and decrease a person’s risk of transmission Explain ways to prevent HIV transmission

3. 3 Why Should Clinicians be Concerned About HIV Prevention? HIV is a communicable disease - affects individuals and the entire community HIV is 100% preventable Best way to stop HIV epidemic in Vietnam is through prevention Patients and family members have many questions about HIV and need accurate advice and quality counseling

4. 4 How is HIV Transmitted? Blood/Parentally IV drug use Occupational exposure (needle sticks) Unprotected sexual contact with infected partner/s Heterosexual or homosexual Perinatally (mother to child) During pregnancy and labor Through breastfeeding

5. 5 Estimated HIV Risk for a Single Exposure to HIV Source Blood Transfusion Mother to child IDU needle sharing Occupational needle stick Receptive anal sex Receptive vaginal sex Insertive anal sex Insertive vaginal sex Receptive oral sex Insertive oral sex (CDC, MMWR, 2005) 90% 25-35% 0.67% 0.3% 0.5% 0.1% 0.065% 0.05% 0.01% 0.005%

6. 6 What Characterizes HIV Transmission? HIV is spread only through exposure to certain bodily fluids: Blood Semen Vaginal secretions Breast milk In order for HIV to be spread, infected fluids need to be exposed to: a mucous membrane (vagina, eye, mouth) broken skin blood (needle stick, infusion) HIV is difficult to transmit even through risky behaviors

7. 7 How is HIV not Spread? HIV is NOT transmitted through casual contact such as: Hugging or kissing Coughing or sneezing Sharing utensils, cups or bowls Sharing toilets Swimming pools Insect bites

8. 8 Prevention of HIV Transmission through Blood/Parental Sources

9. 9 HIV Transmission Through Blood: Injection Drug Users What factors might increase risk of HIV transmission through drug use? Use of previously used syringes Lack of access to clean syringes Lack of effective drug abuse treatment Increased chance of risky sexual behaviors due to diminished judgment

10. 10 Partner Discussion: How can Providers help Reduce HIV Transmission Among IDU?

11. 11 How Providers Can Help Reduce HIV Transmission Among IDU (1) Recognize drug use: Ask all patients about drug use Recommend HIV testing for IDU Help IDU reduce their risks: Educate patients on HIV transmission Counsel on safe injecting behaviors Refer for drug treatment Methadone

12. 12 How Providers Can Help Reduce HIV Transmission Among IDU (2) Explain how to clean syringes: 2 x 2 x 2 (water, bleach, water) Bleach (ideally) for 30 seconds each pass If no bleach, use alcohol (NOT wine, beer) Boiling for 5-10 minutes also kills HIV If can’t use bleach, alcohol, or boil, then use clean water for 30 seconds each time x 3 times

13. 13 Prevention of HIV Transmission Among Sexual Partners

14. 14 Sexual Transmission of HIV (1) HIV is concentrated in semen in men, vaginal secretions in women HIV is more easily transmitted from the insertive to the receptive partner E.g. man to woman during vaginal sex Risk of transmission depends on route of sex: Oral < Vaginal < Anal Lower Risk Higher Risk

15. 15 Sexual Transmission of HIV (2) HIV transmission is INCREASED by: More sexual partners (FSW, MSM) Presence of STIs especially genital ulcers Anal intercourse Trauma during sex Sexual violence, rape Sex during menses

16. 16 Sexual Transmission of HIV (3) HIV transmission is REDUCED by: Fewer Sexual Partners Condom use Non-penetrative sex (masturbation) Male circumcision Lowering HIV viral load with antiretroviral therapy

17. 17 Group Brainstorm: How can providers reduce or PREVENT the sexual transmission of HIV?

18. 18 Prevention of Sexual Transmission of HIV: the ABC’s A Abstinence (no sex) B Be Faithful (one sexual partner) C Condoms (if A & B not followed)

19. 19 How Providers can Reduce Sexually Transmitted HIV 1. Take a sexual history from all patients 2. Provide information on HIV risk behaviors, prevention strategies 3. Counsel and assist patient to disclose status to partner(s) 4. Diagnose and treat STIs 5. Treat with ARVs, as needed

20. 20 HIV Prevention: Condom Use (1) Male latex condom Correct use decreases risk for sexual transmission Female condom Polyurethane Protection appears similar to male condom Lubricants Use for anal or vaginal sex to decrease HIV risk Use only WATER- BASED lubricants Oil-based lubricants can break condom

21. 21 HIV Prevention: Condom Use (2) Basic principles of male condom use: Do not use if expired or package broken Use condom for every act of sexual intercourse Use condom correctly each time Never wash or re-use a condom

22. 22 HIV Prevention: Condom Use (3) Basic principles of female condom use: Can be: safely re-used inserted prior to intercourse used with any lubricant controlled by the woman Does not require: erect penis immediate removal

23. 23 Demonstration: Use of Male Condom Collect necessary items: Penis model New male condom Demonstrate how to use a male condom: Wash hands with soap Inspect condom for tears, holes, expiration date Remove condom from packet Make sure folds are facing up for easy rolling Press tip tight, place on an erect penis by rolling up to pubis so it covers whole penis

24. 24 Demonstration: Use of Female Condom Collect necessary items: Vagina model New female condom Demonstrate how to use a female condom Wash hands with soap Inspect for tears, holes, expiration date Remove condom from packet Pinch/squeeze inner ring into shape of an “8”, introduce high into vagina until fits cervix Place outer ring well around vaginal opening

25. 25 Prevention of Mother to Child Transmission (PMTCT)

26. 26 Mother To Child Transmission HIV transmission from mother to child can occur: in utero during delivery post-partum through breast milk Risk of child acquiring HIV: No treatment: 25- 35% PMTCT: <2% – 5%

27. 27 Prevention of Mother To Child Transmission (PMTCT) In the outpatient clinic (OPC): 1. Provide HIV counseling and testing to all pregnant women 2. Treat eligible HIV+ pregnant women with ARVs, refer to PMTCT program 3. Refer pregnant women who are not eligible for ARVs to PMTCT program for prophylactic ARV

28. 28 Key Points The three routes of HIV transmission are: blood, sex and mother to child HIV is difficult to transmit, easy to prevent Prevention strategies include: Doctors taking a history of risk behaviors, counseling patients on HIV prevention IDUs using new or clean syringes Everyone engaging in safer sexual practices (e.g. condom use)

29. 29 Thank you! Questions?