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Women & HIV

Women & HIV. Jennifer Ballard Dwan, MD Assistant Professor, OB/GYN Boston University Medical Center. Women & HIV. Introductions How did I get here? Clinical case History: The epidemic from past to present HIV/AIDS here and now Changing Lives Resources. Jennifer.Dwan@BMC.org.

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Women & HIV

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  1. Women & HIV Jennifer Ballard Dwan, MD Assistant Professor, OB/GYN Boston University Medical Center Jennifer.Dwan@BMC.org

  2. Women & HIV • Introductions • How did I get here? • Clinical case • History: The epidemic from past to present • HIV/AIDS here and now • Changing Lives • Resources Jennifer.Dwan@BMC.org

  3. Introductions • Who am I? • Currently Asst. Professor of OB/GYN at Boston Medical Center • Obstetric director, Positive HOPE • Maternal-Fetal Medicine specialist Jennifer.Dwan@BMC.org

  4. Introductions • How did I get here? • Lots of books: • And the Band Played On – Randy Shilts • My Own Country - Abraham Verghese • Books on epidemiology and discovery of disease • Undergrad / Med School at UMich • Rotations at CDC • Residency, Fellowship, & Research Jennifer.Dwan@BMC.org

  5. Clinical Case Jennifer.Dwan@BMC.org Accessrx.com

  6. Clinical Case • FG presented to ER with headache and seizures. • 37yo Ugandan asylee, in US x 7 years • MRI concerning for either brain lymphoma or toxoplasmosis • Oral thrush (yeast infection) • Boyfriend 2 years, no h/o STDs • Doctors offered HIV testing: declined, “too scared” • Offered CD4 cell counts = 42 (normal > 500) Jennifer.Dwan@BMC.org

  7. Clinical Case • What are FG’s barriers to testing? • Fear of a positive diagnosis • AIDS = Death • Poor understanding of available treatments • Relationships • Infidelity or untruthfulness in partner • Loss of partner • Community reaction • Financial risk • Concerns of cost of testing / treatment • Loss of insurance coverage Jennifer.Dwan@BMC.org

  8. Women & HIV • Introductions • History: The epidemic from past to present • HIV/AIDS here and now • Changing Lives • Resources Jennifer.Dwan@BMC.org

  9. UN dept of social economic affairs. Millennium Development Goals: Report 2010 Jennifer.Dwan@BMC.org

  10. Brief History of HIV • HIV has been found in human blood from 1959 • Likely descended from single SIV virus in 1940s-50s • June 5, 1981: Initial case report of clusters of rare diseases in gay men • 1982 – Acquired Immune Deficiency Syndrome defined • 4 key risk factors: homosexuality, IV drug abuse, Haitian origin, and hemophilia A CDD FAQ: http://1.usa.gov/s03GqC Jennifer.Dwan@BMC.org

  11. Brief History of HIV • 1983 – (HIV) virus discovered • 5th risk group added: women with AIDS + sexual partners • 1985 – First PMTCT guidelines, • first HIV test available for blood testing • 1987 – First antiretroviral drug (ZDV) approved by FDA • 1988 – WHO reports Women > Men with HIV in Africa • 1990 – Ryan White CARE Act funds community agencies for treatment / testing • 1994 – USPHS & ACTG 076 Trial recommends ZDV for pregnant women to prevent MTCT • NIH requires increases in women / minorities in HIV research http://www.kff.org/hivaids/timeline/hivtimeline.cfm Jennifer.Dwan@BMC.org

  12. Brief History of HIV • 1995 – Peak deaths in US: 75,457 • Highly active anti-retroviral therapy (HAART) • 1997 – US HIV deaths decline by 40% • 2000 – MA is first state to give Medicaid to low-income people with HIV • 2002 – UNAIDS: Women = ½ of HIV infections worldwide • 2003 – PEPFAR: world HIV, TB, and Malaria assistance Jennifer.Dwan@BMC.org

  13. Brief History of HIV • 2006 – CDC: Routine HIV screening for 13-64yo, annually for high risk groups • 2010 – Official US Gov’t travel & immigration ban on HIV+ people lifted • Ban lifted on federal funds for needle exchanges • 2013 – UNAIDS states new infections down 33% Jennifer.Dwan@BMC.org

  14. Jennifer.Dwan@BMC.org www.WHO.int/en

  15. Women & HIV • Introductions • How I got here today • Clinical case • History: The epidemic from past to present • HIV/AIDS here and now • Changing Lives • Resources Jennifer.Dwan@BMC.org

  16. HIV/AIDS 2013 1.1M living with HIV in US • ~50,000 new infections / yr • New infections in women: • Heterosexual (84%) • IVDU (16%) • 21% decrease from 2008  2010 (9,500 women) Jennifer.Dwan@BMC.org http://www.cdc.gov/hiv/pdf/statistics_basics_factsheet.pdf

  17. Black / AA are 14% of the population but acquire 44% of new HIV infections HIV/AIDS 2013 Jennifer.Dwan@BMC.org http://www.cdc.gov/hiv/library/infographics.html

  18. HIV/AIDS 2013 • HIV in Massachusetts • 18,459 people have been diagnosed with HIV in MA • Estimated 4,767 are HIV+ with unknown status (18%) Jennifer.Dwan@BMC.org http://www.mass.gov/eohhs/docs/dph/aids/2013-profiles/epidemic-glance-data.pdf

  19. HIV/AIDS 2013 • As of 2012: ~7,800Women living with HIV in MA • 45% decrease in new HIV dx since 2002 (184 women) • Exposures: • (Presumed) Heterosexual contact = 72% • Drug use = 11% • Undetermined = 17% Jennifer.Dwan@BMC.org http://www.mass.gov/eohhs/docs/dph/aids/2013-profiles/epidemic-glance.pdf

  20. HIV/AIDS 2013 • Incidence higher for non-white women • Black = 1,124 / 100,000 (25x) • Hispanic = 557 / 100,000 (12x) • White = 46 / 100,000 • Proportionally more HIV+ women are minorities • Black 45%  6% population • Hispanic 27%  8% • White 26%  Jennifer.Dwan@BMC.org http://www.mass.gov/eohhs/docs/dph/aids/2013-profiles/epidemic-glance.pdf

  21. HIV/AIDS 2013 • Dec 2012: • 149 / 100,000 women living with HIV in MA • 23x higher prevalence in Black women • 12x higher in Hispanic women • 5 / 100,000 women in MA had a new HIV diagnosis (‘08-’12) Jennifer.Dwan@BMC.org http://www.mass.gov/eohhs/docs/dph/aids/2012-profiles/differential-impact.pdf

  22. http://www.thepromota.co.uk

  23. HIV/AIDS 2013 • Risky sex is common: • 82% women reportno condom use at last sexual encounter • Monogamous relationship 69% • Other contraception 15% • 45% School-age women have had sex • 11% report 4+ sexual partners • 51% report condom use last encounter Jennifer.Dwan@BMC.org

  24. Clinical Case Jennifer.Dwan@BMC.org Accessrx.com

  25. Clinical Case • FG decided to get tested 1 month later (2003): HIV+ with AIDS • By 2004, still did not tell BF, but thought he was positive and seeing a doctor • Condom use “most of the time” • 2009 new sexual partner vs. same partner • HIV positive? • Partner “reluctant to use condoms” • Requests “discreet” contraception • 2010 planning pregnancy – no ART change • 2011 pregnancy

  26. Clinical Case • What are the barriers to discussing HIV+ status? • Fears of emotional abandonment • Partner • Family members / friends • Financial • Rent, other expenses • Fear of job loss • Stigma • Associated with promiscuity, drug use, MSM Jennifer.Dwan@BMC.org

  27. It is currently against Massachusetts law for a person’s HIV status to be revealed to a third party without permission Jennifer.Dwan@BMC.org

  28. Changing Lives Jennifer.Dwan@BMC.org Cfr.org

  29. HIV Treatment / Prevention • Education / Empowerment • Condoms / Circumcision • PMTCT • Addiction treatment / Needle programs • HAART • HIV prophylaxis Jennifer.Dwan@BMC.org

  30. HIV Treatment / Prevention • Education / Empowerment • The more people know, the less they spread HIV • Higher education level • Understanding mode of transmission • Improved social standing = More control • Financial independence • Family planning • Decreased sexual violence Jennifer.Dwan@BMC.org

  31. HIV Treatment / Prevention • Condoms / Circumcision • Latex Condoms • decrease HIV viral exposure • Reduce STIs that increase HIV acquisition • Prevent pregnancy • Male Circumcision • Drastically reduces M  F transmission • Reduces male STIs Jennifer.Dwan@BMC.org

  32. HIV Treatment / Prevention • PMTCT • Without ART, HIV+ mothers will haveHIV+ babies 25% of the time • New infections in pregnancy increase MTCT • High viral loads • Virus crosses placenta? • Breastfeeding alone carries ~12% risk of HIV Jennifer.Dwan@BMC.org

  33. HIV Treatment / Prevention • PMTCT • Medications decrease risk • With medications only at delivery, risk is 8% • With HAART and delivery meds, risk is ~1% • No breastfeeding in US, but recommended where water quality is poor • Decreased infant mortality overall (cholera, other infections) Jennifer.Dwan@BMC.org

  34. HIV Treatment / Prevention • Addiction treatment / Needle programs • Treatment for addiction reduces • Likelihood of needle sharing • Risky sexual behavior • Sex-for-Drugs or Sex-for-Resources • Reducing needle sharing decreases HIV, HCV and HBV sharing • HIV is more infectious with hepatitis present Jennifer.Dwan@BMC.org

  35. HIV Treatment / Prevention • HAART (Highly Active Anti-Retroviral Tx) benefits • Individuals: • Decreases plasma viral load and infectivity • Slows progression to AIDS • Society: • Decreases community viral load • Slows rate of new cases • Generations: • Decreases PMTCT • Reduces age groups decimated due to HIV Jennifer.Dwan@BMC.org

  36. HIV Treatment / Prevention • HIV Prophylaxis • Novel medications • Microbicides • HIV vaccine • HIV medications to HIV- persons at risk • Tenofovir PrEP • Oral medications Jennifer.Dwan@BMC.org

  37. Clinical Case Jennifer.Dwan@BMC.org Accessrx.com

  38. Clinical Case • Pregnancy • Prior SAB x 1, TAB x 1 • Risks: HIV/AIDS, Age, Medication exposure, HTN, Hep B, HSV • Normal labs, testing for Down syndrome • Attended 13 prenatal visits (!!) • Undetectable viral load, BC plan, delivery plan, term pregnancy …and… Jennifer.Dwan@BMC.org

  39. Clinical Case • …Delivered emergently at community hospital • Abruption, blood exposure for baby • No medication prior to delivery • Refused medical records release • Declined “just in case” meds for baby • Came to BMC 4 days after delivery for baby medications • Late prescription filling – more time lost Jennifer.Dwan@BMC.org

  40. Clinical Case • The aftermath: • Distraught OB/GYN, ID, and Pediatrics care givers • ? Filing of 51-A (Child abuse and neglect) • Still with non-disclosure to sexual partner • Baby girl remains HIV negative to date (whew!) Jennifer.Dwan@BMC.org

  41. Social Support Disclosure Housing Discrimination Denial Stigma Fear Privacy Jennifer.Dwan@BMC.org

  42. Resources • HIV / AIDS Action of MA • http://AAC.org • HIV Drug Assistance Program (HDAP) • http://www.crine.org/hiv_drug_assistance_program.html • MA Resources.org • http://www.massresources.org/hiv.html • National HIV Consultation Center: • (800)933-3413

  43. Reading & Resources • Kaiser Foundation HIV timeline • http://bit.ly/tAvW2Y • 2011 US HIV statistics report (CDC): • http://1.usa.gov/1fCTGVS • 2013 MA data fact sheet: • http://1.usa.gov/1fCTkPg • ACTG 076 Trial of PMTC: • http://bit.ly/ACTG076 • AIDSInfo.gov – up to date treatment / testing info Jennifer.Dwan@BMC.org

  44. THANK YOU Jennifer.Dwan@BMC.org

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