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How does the Internet affect HIV prevention?

why the Internet?

The Internet has become a remarkable social networking tool where people who once were unlikely to meet in the physical world are now only a few key strokes away. It is not surprising that many persons with access to the Internet have used it to find love, companionship and sex.¹ In fact, using the Internet to find sexual partners is a widespread practice among men and women of all ages. About 16 million people say they have used websites to meet other people.² Men who have sex with men (MSM)—whose sexual activities traditionally have been stigmatized—have benefited from the privacy of the Internet, with 40% of gay men reporting that they use the Internet to find sexual partners.³ In online interviews, gay men reported that the Internet has helped them find social support, access resources safely and anonymously, and develop significant personal relationships.⁴ The Internet is important to the HIV prevention field. It is a powerful medium to deliver health and risk-reduction information. Many individuals who engage in risk-taking behaviors use the Internet to meet their sexual partners, and the Internet itself may facilitate such risk-taking behaviors.

does the Internet contribute to risk?

Whether or not the Internet’s unique qualities contribute to risk-taking behaviors is not fully understood. We know that people who use the Internet to meet sexual partners have been found to engage in more risky sexual behavior, be more likely to report a history of STDs, and have greater numbers of sexual partners than those who do not seek sexual partners online.^3,5 In fact, as early as 1999, outbreaks of syphilis among MSM were traced to users of specific chatrooms,⁶ and there are also case reports of HIV transmission from sexual partners met online.⁷ It has been found, though, that men who engage in high-risk behaviors do so regardless of whether they meet their partners online or offline, such as in bars and clubs.⁸ Gay and bisexual men with “psychosocial vulnerabilities” (e.g., safer-sex burnout, depression, and social isolation) may be particularly prone to disengage, or avoid thinking about HIV, in the anonymity of a virtual world where they can meet sexual partners for engaging in high-risk sexual behaviors.⁹ Using the Internet to meet partners outside one’s regular sexual network may also create an environment where sexual mixing between high-risk and low-risk persons occurs.¹⁰ These new, expanded sexual networks can, in turn, increase the rate at which HIV and other STDs are transmitted.

can the Internet help in prevention?

Absolutely. The anonymity of online communication may make it easier to disclose HIV status or discuss safer sex and condom use before meeting in person.¹¹ A study of Latino MSM found they were significantly more likely to engage in sexual negotiation and serostatus disclosure on the Internet than in person. For HIV+ persons, disclosing HIV status online also helps avoid abuse, discrimination or rejection by partners.¹² The Internet also provides a way to find sex partners who like the same things and are willing to take the same amount of risk. It may afford more opportunities to chat with a potential partner before having sex. In online ads, individuals can clearly state that they’re looking for partners who agree to safer sex (such as condom use), and they can more easily avoid meeting those who do not. Similarly, online sex-seeking allows HIV+ persons to disclose their status and find partners of the same serostatus (often called serosorting), especially if they intend not to use condoms.⁸ Just like in the physical world, however, one cannot be fully trusted to give or even know their accurate HIV status, so serosorting may not be a foolproof HIV prevention strategy, and it also risks transmitting other STDs.

what’s being done?

Community-Based Organizations (CBOs), researchers, and health departments—occasionally with the support of online service providers—are using the Internet in creative ways to increase HIV-related awareness and knowledge, and to positively influence attitudes, beliefs, and behaviors. Researchers have used the Internet to recruit participants and to collect data. Internet-based programs have also been used to help people anonymously disclosure their HIV/STD status to past sexual partners. Commonly, CBOs have used e-mail distribution lists or sent outreach workers into popular online meeting venues (such as chat rooms and hook-up sites) to promote their programs, answer questions, deliver educational and safer-sex materials, and encourage dialogue about HIV prevention. A handful of CBOs with dedicated funding created HIV-prevention websites tailored for their communities.¹³ Launched in 2002, PowerOn is a comprehensive site providing access to HIV/AIDS education, support, and referrals to 200 local prevention agencies for the gay, bisexual and transgender community in Seattle/King County, WA. Early PowerOn users showed particular interest in pages about Negotiating Safety Agreements and Putting on a Condom.¹⁴ Wrapp.net provides HIV prevention interventions and resources for MSM in the rural US. One NIMH-funded intervention presented a conversation between an HIV+ and an HIV- gay man who recently engaged in risk behavior. A randomized controlled trial found it was well accepted and improved participants’ HIV risk-reduction knowledge, safer-sex attitudes, beliefs about what will happen as a result of engaging in certain behaviors, and beliefs about how well they can perform a given task.¹⁵ Once computerized online interventions are developed, they can operate cost-effectively around the clock, can be easily modified whenever changes are necessary, and quality control standards can be readily established with little opportunity for human error. Community members with Internet access can use such programs at their convenience and with little risk to their personal privacy. Many health departments are exploring using the Internet for partner notification, disclosure assistance and referrals.¹⁶ InSPOT.org, developed by ISIS, Inc., is a website where men diagnosed with HIV /STDs can send electronic cards to sexual partners to inform them of a potential exposure, conveniently and without intervention by a provider. Cards can be sent anonymously, with or without a personal message. A survey of MSM in San Francisco found that 19% had heard of InSPOT, 5% of those used it to notify a partner and 4% received an e-card. Popular website owners can also participate in HIV prevention and education activities. Craigslist.org agreed to add a health message and link to the San Francisco City Clinic website for users entering the “men seeking men” and the “casual encounters” pages. This addition did not result in a decline in the number of postings or visitors. Manhunt agreed to place ads on the dangers of crystal meth use and the rise in syphilis cases. Gay.com accepted a request to integrate sexual health messages by linking to “Ask Dr. K,” a question-and-answer sexual-health forum.¹⁷

what needs to be done?

New interventions to address the HIV risks associated with the Internet need to be developed and evaluated. Programs that help people think about their motives for seeking partners online, and Web-based, health-related screening and referral tools may be promising approaches. It is crucial to conduct further evaluations of the efficacy of current online prevention programs before any such interventions and approaches can be deemed successful and worth replicating. Social policies to help prevent Internet-facilitated HIV transmission are also necessary and may come from legislation or from voluntary changes enacted by website operators. Cooperative efforts between online providers, law makers, researchers, program planners and, most importantly, community members could create structural changes to prevent further Internet-facilitated HIV transmissions.¹⁸ Options for policy changes include: public-health warnings on websites; changes to the way hookup sites are advertised; encouraging research to measure behavior change from online interventions and the development of tools on dating or hookup sites that facilitate the discussion of HIV and safer sex; and incentives for website operators to cooperate with public-health and other HIV-prevention efforts.

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Says who?

1. Chiasson MA, Parsons JT, Tesoriero JM, et al. HIV behavioral research online.Journal of Urban Health. 2006;83:73-85. 2. Madden M, Lenhart A. Online dating. Report prepared by the Pew Internet and American Life Project. March 2006. 3. Liau A, Millett G, Marks G. Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men. Sexually Transmitted Diseases. 2006;33:576-584. 4. Rebchook G, Curotto A, Kegeles S. Exploring the sexual behavior and Internet use of chatroom-using men who have sex with men through qualitative and quantitative research. Presented at the 2003 National HIV Prevention Conference, Atlanta, GA. 5. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. Journal of the American Medical Association. 2000;284:443-446. 6. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. Journal of the American Medical Association. 2000;284:447-449. 7. Tashima K, Alt E, Harwell J, et al. Internet sex-seeking leads to acute HIV infection: a report of two cases. International Journal of STD and AIDS. 2003;14:285-286. 8. Bolding G, Davis M, Hart G, et al. Gay men who look for sex on the Internet: is there more HIV/STI risk with online partners? AIDS. 2005;19:961-968. 9. McKirnan D, Houston E, Tolou-Shams M. Is the Web the culprit? Cognitive escape and Internet sexual risk among gay and bisexual men. AIDS and Behavior. 2006. 10. Wohlfeiler D, Potterat JJ. Using gay men’s sexual networks to reduce sexually transmitted disease (STD)/human immunodeficiency virus (HIV) transmission. Sexually Transmitted Diseases. 2005;32:S48-52. 11. Carballo-Dieguez A, Miner M, Dolezal C, et al. Sexual negotiation, HIV-status disclosure, and sexual risk behavior among Latino men who use the internet to seek sex with other men. Archives of Sexual Behavior. 2006;35:473-481. 12. Davis M, Hart G, Bolding G, et al. Sex and the Internet: gay men, risk reduction and serostatus. Culture, Health and Sexuality. 2006;8:161-174. 13. Curotto A, Rebchook G, Kegeles S. Opening a virtual door into a vast real world: Community-based organizations are reaching out to at-risk MSM with creative, online programs. Paper presented at: STD/HIV Prevention and the Internet; August 27, 2003; Washington D.C. 14. Weldon JN. The Internet as a tool for delivering a comprehensive prevention intervention for MSM Internet sex seekers. Paper presented at: 2003 National HIV Prevention Conference; July 27-30, 2003, 2003; Atlanta, GA. depts.washington.edu/poweron/ 15. Bowen AM, Horvath K, Williams ML. A randomized control trial of Internet-delivered HIV prevention targeting rural MSM. Health Education Research. 2006.www.wrapp.net 16. Mimiaga MJ, Tetu A, Novak D, et al. Acceptability and utility of a partner notification system for sexually transmitted infection exposure using an internet-based, partner-seeking website for men who have sex with men. Presented at the International AIDS Conference, Toronto, Canada. 2006. Abstr #THPDC02. 17. Klausner JD, Levine DK, Kent CK. Internet-based site-specific interventions for syphilis prevention among gay and bisexual men. AIDS Care, 2004;16:964-970. 18. Levine D, Klausner JD. Lessons learned from tobacco control: A proposal for public health policy initiatives to reduce the consequences of high-risk sexual behavior among men who have sex with men and use the Internet. Sexuality Research and Social Policy. 2005;2:51-58.

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Prepared by Greg Rebchook PhD, Alberto Curotto PhD, CAPS and Deb Levine, ISIS January 2007. Fact Sheet #63E Special thanks to the following reviewers of this fact sheet: Anne Bowen, Cari Courtenay-Quirk, Jonathan Elford, Charles King, Jeff Klausner, Mary McFarlane, Greg Millett, Frank Strona. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©January 2007, University of CA.

Is Mother-to-Child HIV Transmission Preventable?

Prepared by Sarah A. Gutin, MPH* *CAPS, Community Health Systems- School of Nursing, UCSF Fact Sheet #34ER – September 2015 Special thanks to the following reviewers of this Fact Sheet: Yvette Cuca, Carol Dawson Rose, Shannon Weber In 2012, there were 2.3 million new HIV infections globally¹. A large proportion of people newly diagnosed with HIV worldwide are in their reproductive years and these men and women are likely to want children in the future^2-4. Addressing the sexual and reproductive health and rights of this population is critical to addressing the spread of HIV because HIV infection in childbearing women is the main cause of HIV infection in children⁵. Treatment for those who are already infected is also central to stopping the spread of HIV to infants and to uninfected sexual partners. How does transmission occur? Perinatal transmission of HIV, also called vertical transmission, occurs when HIV is passed from an HIV-positive woman to her baby during pregnancy, labor and delivery or breastfeeding. For an HIV-positive woman not taking HIV medications, the chance of passing the virus to her child ranges from about 15 to 45% during pregnancy, labor and delivery. If she breastfeeds her infant, there is an additional 35 to 40% chance of transmission⁶. Is the risk of perinatal transmission always the same? No. Global societal and economic inequities create a wide gap between women in developing nations and women in developed nations with regard to HIV prevention, voluntary counseling and testing and access to drugs which treat HIV infection and can prevent perinatal transmission. Developed countries- In many developed countries, pediatric HIV has been virtually eliminated⁷. In the US in 1994, the Public Health Service recommended HIV counseling and voluntary testing and AZT therapy for all pregnant women after the clinical trial known as “076” showed that AZT reduced rates of MTCT by two-thirds. Since then, a combination of interventions that includes treatment with ART to control the virus and make it undetectable, cesarean delivery, and avoidance of breastfeeding has helped further reduce perinatal transmission in the US, from an estimated 1,500 cases in 1992 to an estimated 162 perinatal infections in 2010⁸. Although the estimated number of perinatal HIV infections in the US continues to decline, women of color, especially black/African American women are disproportionately affected by HIV infection and as a result, perinatal HIV infection is highest among blacks/African Americans (63%), followed by Hispanics/Latinas (22%)⁸. Although effective interventions have led to a significant reduction in the number of perinatal infections in the US, perinatal transmission still occurs. To close the final gap, the CDC has proposed a new framework to eliminate mother-to-child HIV transmission (EMCT) in the US⁸. This framework focuses on key areas including: comprehensive reproductive health care (that includes both family planning (FP) and preconception care) and comprehensive case-finding  of pregnancies in HIV-infected women that is conducted through comprehensive clinical care  and case management services for women and infants; case review and community action; continuous quality research in prevention and long-term monitoring of HIV-exposed infants; and thorough data reporting for HIV surveillance at the state and local health department levels^8,9. Developing countries- Unfortunately, perinatal transmission of HIV continues to plague many developing countries despite recent prevention acceleration. In 2008, an estimated 1.4 million pregnant women in low and middle-income countries were living with HIV, of whom about 90% were in sub-Saharan African countries⁷. In 2012, UNAIDS reported that approximately 210,000 children became HIV infected¹. Can perinatal transmission of HIV be reduced? Yes. Perinatal transmission encompasses a variety of highly effective interventions that have huge potential to improve maternal and child health. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of perinatal transmission worldwide. Also, perinatal transmission can be reduced by preventing unintended pregnancies.  Preventing unintended pregnancies is one of the most effective ways to prevent HIV infection in infants and stop spread of the epidemic to children¹⁰. For that reason, preventing unintended pregnancies among women living with HIV and offering family planning to delay, space or end childbearing is one of the four WHO pillars in the comprehensive approach to preventing perinatal transmission⁷. However, we have still not addressed the root cause of perinatal transmission, mainly heterosexual HIV transmission. The best way to prevent perinatal HIV transmission is to prevent HIV transmission in the mother and father. In order to reduce perinatal transmission, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counseling. If a pregnant woman is HIV-positive, she should have access to lifelong ART to treat HIV and improve her own health and to decrease the chances of HIV infection in her infant. In June 2013, the WHO published updated guidelines on the diagnosis of HIV, the care of people living with HIV(PLHIV) and the use of ART for treating and preventing HIV infection¹. In the US, the Department of Health and Human Services recommends that all HIV-infected pregnant women should be given ART during pregnancy to prevent perinatal transmission of HIV, regardless of whether ART is indicated for the woman’s own health¹¹. Perinatal transmission can be reduced to less than 2% if a woman is on ART, has a low or undetectable viral load, follows the recommended treatment regimen and does not breastfeed^7,8. Careful management during labor and delivery can also help reduce perinatal transmission, for example by avoiding unnecessary instrumentation and not prematurely rupturing membranes¹². Also, although universal prenatal HIV testing is the standard in the US, if prenatal care has not been provided, the patient has HIV, or her HIV status is undocumented, it is critical for hospitals to determine a laboring patient’s HIV status upon admission. Even without the use of ART during the pregnancy, the use of ART during labor and for the infant can reduce the risk of perinatal transmission to between 6 to 13%¹³. It is therefore recommended that rapid HIV testing be performed in Labor and Delivery units on pregnant women with no HIV test during their pregnancy or with risk factors for infection since their last test¹⁴. In developing countries, perinatal transmission has been a priority since 1998, following the success of short-course zidovudine and single-dose nevirapine clinical trials⁷. In recent years, single-dose nevirapine as the primary antiretroviral medicine option for HIV-positive pregnant women to prevent transmission to their infants has been phased out, in favor of more effective and simplified triple ART regimens¹.  The WHO now recommends that all pregnant and breastfeeding women with HIV, regardless of CD4 count or clinical stage, should initiate a triple ART regimen which should be maintained for the duration of perinatal transmission risk, which includes pregnancy, delivery and throughout the breastfeeding period (this is known as Option B). In countries were more than one percent of the population has HIV (these are known as generalized epidemics) and where there is often limited access to tests that indicate the severity of HIV illness (such as CD4 testing), limited partner testing, long duration of breastfeeding and high rates of fertility, the WHO recommends that women meeting treatment eligibility criteria should continue lifelong ART (this strategy is referred to as Option B+)¹². There are many benefits to lifelong treatment for all pregnant and breastfeeding women and these include increased coverage of those needing ART for their own health, a reduction in the number of women stopping and starting ART during repeat pregnancies, early protection against perinatal transmission in future pregnancies, reduced risk of infecting a partner who is HIV-negative and decreased risk of medication failure or the development of resistance¹². The ultimate goal is to find the most effective and sustainable regimens for HIV treatment and the prevention of perinatal transmission worldwide. Economics, politics, poor infrastructure, access to healthcare and medications, stigma and cultural norms all pose significant challenges to providing this standard of care everywhere and not all PLHIV have equal access to treatment. What are the barriers to the prevention of perinatal transmission? Pregnant women face many difficult decisions, including decisions around HIV testing, treatment options and infant feeding. Understanding the barriers that women face and addressing barriers at various levels can help in realizing the full potential of prevention of perinatal transmission programs. A recent review article found that barriers to the prevention of perinatal transmission often fell into three broad categories that included the individual, their partners and community, and health systems¹⁵. At the individual level, studies suggest that a lower maternal education level, younger maternal age, and poor knowledge of HIV transmission and ART are associated with not receiving and/or not taking ART in order to treat and prevent the spread of HIV¹⁵. Additionally, a woman’s male partner(s), extended family, greater community and health care setting all influence her decision and ability to take advantage of prevention of perinatal transmission programs. Many qualitative studies have found that stigma regarding HIV status and fear of disclosure to partners and family members is a major barrier to the uptake of perinatal prevention interventions¹⁵. Women living with HIV also continue to report that stigma and discrimination, especially in health care settings, continue to be a barrier to accessing adequate information and services¹. In various studies, PLHIV have reported negative staff attitudes and this has been cited as a barrier to returning to facilities for care¹⁵. In developing countries, health systems issues are also a barrier to greater prevention uptake. Key barriers that have been identified include a shortage of trained clinic staff, high patient volumes, long wait times, and brief and poor counseling sessions¹⁵. In addition, a lack of access or shortages of medications, including ART, as well as stock-outs of HIV test kits and condoms have been reported.  Poor access to healthcare overall (long distances to facilities) and poor integration of services also contributes to low ART uptake. What about breastfeeding? Breastfeeding is usually the healthiest choice for both infants and mothers. However, HIV transmission can occur during breastfeeding, with chances of transmission increasing the longer the infant is breastfed. In the countries with the highest perinatal HIV rates, it is estimated that more than half of the children newly infected with HIV acquire it during the breastfeeding period¹. However, the risk of transmitting HIV to infants through breastfeeding is low in the presence of ART¹². Therefore, providing ART to mothers throughout the breastfeeding period is a critical step needed to further reduce rates of perinatal transmission¹. It is recommended that HIV-positive mothers do not breastfeed when formula feeding is safe, well accepted and readily available. In the US, both the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommends that HIV-infected women refrain from breastfeeding regardless of their ART status to avoid postnatal transmission of HIV to their infants through breast milk^16,17. However, formula feeding requires clean water for mixing formula. Many women in developing countries do not have access to clean water or sanitation and cannot afford formula, and therefore cannot avoid breastfeeding. In developing countries where breastfeeding is the norm, formula feeding may also alert a woman’s family or community that she is HIV-positive, which may result in stigma or other negative repercussions. Therefore, the WHO recommends that when breastfeeding is unavoidable, mothers should take ART while breastfeeding and that infants should receive 6 weeks of prophylaxis with once-daily nevirapine¹². The WHO further recommends that mothers known to be infected with HIV (and whose infants are HIV uninfected or of unknown status) should exclusively breastfeed for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. It is recommended that breastfeeding should only stop when a nutritionally adequate and safe diet without breast-milk can be provided¹². Access to ARVs during this extended breastfeeding period is critical¹². What’s being done? Primary prevention of HIV among men and women of childbearing age: Various tools are now available to prevent HIV infections in men and women of childbearing age. Pre-exposure prophylaxis (PrEP), which is a special course of HIV treatment that aims to prevent people from becoming infected with HIV, has been found to protect against HIV-1 infection in heterosexual men and women and reduce HIV transmission by 67 to 75%^18,19. PrEP is intended for people at-risk of becoming infected with HIV, for example in the case of couples where one partner is HIV-positive and the other is HIV-negative. In countries with generalized HIV epidemics, voluntary medical male circumcision for HIV-negative male partners in relationships with a positive partner has been shown to reduce the risk of HIV-acquisition in men by between 38% to 66%²⁰. Using ART to decrease the chance of HIV transmission, a concept known as treatment as prevention, has also recently been found to be very efficacious, with studies in heterosexual populations showing that adherence to ART is very effective at preventing transmission of HIV to HIV-negative partners^21-23. Couples-testing with treatment for infected partners in discordant partnerships is also a promising approach. Integrating couples counseling and partner testing into routine clinic and community services  can increase the number of couples in which the status of both partners is known and can help identifying sero-discordant couples²⁴. Preventing unintended pregnancies and Safer Conception Options: Preventing unintended pregnancies among women living with HIV (WLHIV) is a powerful prevention strategy. One study found that even modest reductions in the numbers of pregnancies among WLHIV could avert HIV-positive births at the same rates as the use of ART for PMTCT²⁵. One targeted approach to strengthening FP programs is to integrate FP within HIV services. In Kenya, a recent cluster-randomized trial tried to determine whether integrating FP services into HIV care was associated with increased use of more effective contraceptive methods such as sterilization, IUDs, implants, injectables and oral contraceptives. Women seen at integrated sites were significantly more likely to use more effective methods of FP at the end of the study²⁶. This makes the case for integrating FP within HIV care. Reducing the unmet need for FP will reduce new HIV infections among children and improve overall maternal and infant health. For HIV-positive or serodiscordant couples who would like to have children, there are many options available to make conception safer. When offering preconception care, HIV-positive couples will have specific needs, many of which can be addressed during their routine HIV care. When offering preconception counseling for HIV-positive women, the CDC recommends that health care providers should discuss a variety of topics, including: reproductive options and actively assessing women’s pregnancy intentions on an ongoing basis; Counseling on safe sexual practices that prevent HIV transmission to sexual partners, protect women from acquiring sexually transmitted diseases, and reduce the potential to acquire more virulent or resistant strains of HIV;  Using ART to attain a stable, maximally suppressed maternal viral load prior to conception to decrease the risk of perinatal transmission and of HIV transmission to an uninfected partner; and encouraging sexual partners to receive counseling and HIV testing and, if infected, to seek appropriate HIV care¹¹. For couples who want to conceive, in which one or both are HIV-positive, the positive partner should be on ART and have achieved maximal suppression of HIV infection. ART for the positive partner may not be fully protective against sexual transmission of HIV and so the administration of PrEP for the HIV-negative partner may offer an additional tool to reduce the risk of transmission. For discordant couples, when the positive partner is a woman, the safest conception option is artificial insemination. In discordant couples where the positive partner is male,the safest conception option is the use of donor sperm from an HIV-uninfected male with artificial insemination. When the use of donor sperm is unacceptable, the use of sperm preparation techniques together with either intrauterine insemination or in vitro fertilization is an option¹¹. Preventing HIV transmission from WLHIV to infants: Increasing access to ART for WLHIV is critical to saving the lives of women and their children. The number of pregnant WLHIV receiving ART for their own health has increased from 25% in 2009 to 60% in 2012¹. One of the greatest success stories has been in Malawi where a policy of providing lifelong ART to all pregnant and breastfeeding women (irrespective of CD4 count or clinical status– a strategy referred to as Option B+) was enacted in 2011. Since then, Malawi increased the estimated coverage of women in need of ART from 13% in 2009 to 86% in 2012. The implementation of Option B+ has resulted in a 748% increase in the number of pregnant and breastfeeding women starting ART, from 1,257 in the second quarter of 2011 to 10,663 in the third quarter of 2012²⁷. As a result of Option B+, the perinatal transmission rate for women on ART is expected to be reduced, from approximately 40% without intervention to less than 5%. By decentralizing treatment services and offering lifelong HIV treatment to all pregnant and breastfeeding women, Malawi has been able to increase ART coverage both during pregnancy and the breastfeeding period¹. Providing treatment, care and support to WLHIV and their children and families: Increasing access to ART for pregnant women living with HIV for their own health is critical to saving the lives of women and their children. Even developing countries, which at first lagged behind in reducing the number of children newly infected with HIV, have made great gains in recent years. In 2013, UNAIDS reported that in 7 high burden countries where access to treatment has increased, the rates of HIV transmission to children has fallen by 50% or more¹. What still needs to be done? HIV is a preventable disease. Perinatal transmission is best prevented by effective, accessible and sustainable HIV prevention, access to HIV testing, early diagnosis and linkage to treatment programs for women, men and their children, access to family planning and abortion services to prevent unintended pregnancies, and access to an ongoing supply of ARVs to improve the health of women and their children. Structural interventions are also needed that increase access to health centers, improve health care infrastructure, provide food supplementation, and HIV treatments. Women are the key to the HIV response and the number of women acquiring HIV has to be reduced. All women have a right to be treated for HIV infection, not simply because they are bearing a child. All women living with HIV who are eligible for ART need to have access to it. Unfortunately, too many women are still lost along the prevention cascade and never get the care or treatment they need and deserve. Providing women with access to high quality healthcare for themselves and their families, whether they are HIV-positive or not, is imperative.

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Says who?

1. UNAIDS. AIDS by the numbers. Geneva, Switzerland, 2013. 2. Kanniappan S, Jeyapaul MJ, Kalyanwala S. Desire for motherhood: exploring HIV-positive women’s desires, intentions and decision-making in attaining motherhood. AIDS care 2008;20(6):625-30 doi: 10.1080/09540120701660361[published Online First: Epub Date]|. 3. Beyeza-Kashesya J, Kaharuza F, Mirembe F, et al. The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. African health sciences 2009;9(1):2-12 4. Cooper D, Moodley J, Zweigenthal V, et al. Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS and behavior 2009;13 Suppl 1:38-46 doi: 10.1007/s10461-009-9550-1[published Online First: Epub Date]|. 5. UNAIDS. We Can Prevent mothers fom dying and babies from becoming infected with HIV. Geneva, Switzerland, 2010. 6. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA : the journal of the American Medical Association 2000;283(9):1175-82 7. WHO. PMTCT Strategic Vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millenium Development Goals. Geneva, Switzerland, 2010. 8. CDC. HIV Among Pregnant Women, Infants, and Children in the United States. Atlanta, 2012. 9. Nesheim S, Taylor A, Lampe MA, et al. A framework for elimination of perinatal transmission of HIV in the United States. Pediatrics 2012;130(4):738-44 doi: 10.1542/peds.2012-0194[published Online First: Epub Date]|. 10. Nakayiwa S, Abang B, Packel L, et al. Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda. AIDS and behavior 2006;10(4 Suppl):S95-104 doi: 10.1007/s10461-006-9126-2[published Online First: Epub Date]|. 11. Department of Health and Human Services Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. In: Bureau HA, ed. Washington, DC, 2014. 12. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach. Geneva, Switzerland, 2013. 13. Kourtis AP, Lee FK, Abrams EJ, et al. Mother-to-child transmission of HIV-1: timing and implications for prevention. The Lancet infectious diseases 2006;6(11):726-32 doi: 10.1016/S1473-3099(06)70629-6[published Online First: Epub Date]|. 14. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 2006;55(RR-14):1-17; quiz CE1-4 15. Gourlay A, Birdthistle I, Mburu G, et al. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. Journal of the International AIDS Society 2013;16(1):18588 doi: 10.7448/IAS.16.1.18588[published Online First: Epub Date]|. 16. American Academy of Pediatrics Committee on Pediatric A. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics 2008;122(5):1127-34 doi: 10.1542/peds.2008-2175[published Online First: Epub Date]|. 17. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Secondary Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. 18. Celum C, Baeten JM. Tenofovir-based pre-exposure prophylaxis for HIV prevention: evolving evidence. Current opinion in infectious diseases 2012;25(1):51-7 doi: 10.1097/QCO.0b013e32834ef5ef[published Online First: Epub Date]|. 19. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. The New England journal of medicine 2012;367(5):399-410 doi: 10.1056/NEJMoa1108524[published Online First: Epub Date]|. 20. Siegfried N, Muller M, Deeks JJ, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. The Cochrane database of systematic reviews 2009(2):CD003362 doi: 10.1002/14651858.CD003362.pub2[published Online First: Epub Date]|. 21. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010;375(9731):2092-8 doi: 10.1016/S0140-6736(10)60705-2[published Online First: Epub Date]|. 22. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. The New England journal of medicine 2010;363(27):2587-99 doi: 10.1056/NEJMoa1011205[published Online First: Epub Date]|. 23. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine 2011;365(6):493-505 doi: 10.1056/NEJMoa1105243[published Online First: Epub Date]|. 24. Medley A, Baggaley R, Bachanas P, et al. Maximizing the impact of HIV prevention efforts: Interventions for couples. AIDS care 2013 doi: 10.1080/09540121.2013.793269[published Online First: Epub Date]|. 25. Sweat MD, O’Reilly KR, Schmid GP, et al. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. Aids 2004;18(12):1661-71 26. Grossman D, Onono M, Newmann SJ, et al. Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial. Aids 2013;27 Suppl 1:S77-85 doi: 10.1097/QAD.0000000000000035[published Online First: Epub Date]|. 27. Centers for Disease Control and Prevention. Impact of an innovative approach to prevent mother-to-child transmission of HIV–Malawi, July 2011-September 2012. MMWR. Morbidity and mortality weekly report 2013;62(8):148-51

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¿Qué sirve mejor en la enseñanza sobre la sexualidad y el VIH?

¿por qué la enseñanza sobre la sexualidad y el VIH?

Los programas educativos sobre la sexualidad y el VIH tienen varias metas: disminuir los embarazos no planeados, reducir las enfermedades de transmisión sexual (ETS) incluyendo la del VIH y mejorar la salud sexual de los jóvenes. En 2005 en los EE.UU., el 63% de todos los alumnos del último año de preparatoria (high school) habían tenido relaciones sexuales, pero sólo el 21 % de las alumnas usaron pastillas anticonceptivas antes del último coito y sólo el 70 % de los varones usaron condón en el último coito.¹ En el 2000, el 8.4 % de las chicas entre 15 y 19 años se embarazaron, produciendo una de las tasas más altas de embarazo adolescente en el mundo occidental industrializado.² Casi la mitad de los nuevos casos de ETS en EE.UU. del año 2000 (9.1 millones) se presentaron en jóvenes entre los 15 y los 24 años de edad.³ Algunos de los numerosos factores que influyen en la conducta sexual y el uso de protección entre los adolescentes tienen poco que ver con las relaciones sexuales, por ejemplo: la crianza en una comunidad desfavorecida, la falta de apego a los padres o el fracaso escolar. Otros factores de naturaleza sexual como las creencias, los valores, las percepciones de normas de los pares, las actitudes y habilidades relacionadas con la conducta sexual y con el uso del condón o de anticonceptivos,⁴ son factores en los que los programas de enseñanza potencialmente pueden incidir para generar cambios de conducta. Estos programas no pueden por sí solos eliminar las conductas sexuales riesgosas, pero sí pueden ser una pieza eficaz dentro de una iniciativa integral.

¿sirven los programas de enseñanza?

Sí. Algunos programas retrasan el inicio de las relaciones sexuales, disminuyen la frecuencia de las relaciones sexuales, limitan el número de parejas sexuales y aumentan el uso del condón u otro anticonceptivo. Además hay investigaciones que demuestran que los programas de enseñanza sobre la sexualidad/VIH (incluyendo los que promueven el uso de condones y otros anticonceptivos) no aumentan la actividad sexual. En una revisión reciente en EE.UU de programas que han sido evaluados, casi dos tercios mejoraron considerablemente una o más de estas prácticas.⁵ Los resultados fueron aun más positivos en países en vías de desarrollo. Si bien muchos programas son eficaces, otros pueden no serlo; las comunidades deben implementar ya sea los programas con eficacia comprobada o los que incorporen las características comunes de los programas eficaces.⁵

¿es posible replicar programas eficaces?

Sí. Varios currículos implementados y evaluados hasta cinco veces en varios estados de EE.UU. con frecuencia produjeron cambios positivos en la conducta sexual al realizarse tal y como fueron diseñados. De hecho, uno de estos programas fue replicado en más de 80 organizaciones comunitarias y su eficacia quedó comprobada.⁶ Sin embargo, cuando se recortan mucho los currículos, cuando se eliminan las lecciones sobre el condón o cuando los programas diseñados para lugares de la comunidad se llevan a cabo en el aula escolar, se reduce la probabilidad de producir cambios importantes en la conducta.

¿qué currículos logran cambios importantes en la conducta?

• En un ensayo aleatorizado de mujeres jóvenes, el programa SiHLE (las siglas en inglés para hermanar, informar, curar, vivir, empoderar) aumentó considerablemente el uso del condón y redujo la incidencia de embarazos y de ETS.⁷
• En cuatro estudios diferentes, Reducing the Risk logró durante 18 meses bien un retraso en la iniciación de relaciones sexuales o un aumento en el uso del condón.^8,9
• En otro ensayo aleatorizado, Safer Choices retrasó la iniciación del sexo entre algunos jóvenes y aumentó el uso de condones y otros anticonceptivos entre jóvenes sexualmente activos a lo largo de 31 meses.¹⁰
• Finalmente, en varios ensayos aleatorizados, Making Proud Choices¹¹ y Becoming a Responsible Teen¹² aumentaron durante un año el uso de condones.

Estos y otros programas eficaces comparten 17 características que contribuyen a su éxito, las cuales se agrupan bajo el desarrollo, el currículo en sí y la implementación.⁵

¿cómo se desarrollan programas eficaces?

Los programas eficaces se pueden desarrollar por equipos de personas con formación en teoría psicosocial, conducta sexual adolescente, diseño de currículos, cultura comunitaria y/o enseñanza sobre la sexualidad y el VIH. El equipo examina los datos locales sobre la conducta sexual adolescente, las tasas de embarazo y de ETS, y muchas veces realiza grupos de focales con jóvenes y entrevistas con adultos. También utiliza el marco de un modelo lógico para identificar las prácticas que desea modificar, los factores de riesgo y los factores protectores que las afectan, así como las actividades que las harían cambiar. Posteriormente el equipo diseña actividades coherentes con los valores y recursos comunitarios. Finalmente el equipo realiza pruebas piloto y ajusta los currículos.

¿en qué consisten currículos eficaces?

Los currículos eficaces se centran en reducir los embarazos no deseados, las ETS, el VIH o ambos al enfatizar las consecuencias y los peligros que éstos conllevan, presentar un mensaje claro sobre la conducta sexual y comentar las situaciones que pueden llevar a las relaciones sexuales y cómo evitarlas. Los mensajes conductuales son de suma importancia. Los currículos eficaces por lo general enfatizan la abstinencia como el método más eficaz e inocuo (que no daña), y motivan a los jóvenes que ya tienen relaciones sexuales a usar condones y anticonceptivos. A veces se hace hincapié en otros valores (como el orgullo propio, la responsabilidad, el auto respeto, la capacidad de no exceder los límites y la de controlarse) que claramente están vinculados con ciertas conductas en particular. Los currículos eficaces incorporan actividades, métodos docentes y mensajes conductuales que reflejan la cultura, la edad madurativa, el género y la experiencia sexual de los jóvenes. Todos involucran activamente a los jóvenes para ayudarles a personalizar la información.

• Para aumentar los conocimientos básicos sobre los riesgos que conlleva las prácticas sexuales en la adolescencia y sobre métodos para evitar el coito o para usar protección, los programas eficaces pueden emplear: discursos breves, diálogos en clase, juegos competitivos, parodias o dramatizaciones breves, videos y rotafolios o folletos.
• Para aclarar los riesgos, los programas pueden emplear datos sobre la incidencia o la prevalencia del embarazo o de ETS/VIH entre los jóvenes (junto con las consecuencias), diálogos en clase, oradores VIH+ y simulaciones.
• Para modificar los valores individuales y las normas entre pares con respecto a la abstinencia y al uso del condón, los programas pueden emplear: mensajes conductuales nítidos, ejercicios de elección obligatoria de valores, encuestas o votación entre pares, de juegos de interpretación de roles, conversaciones sobre la eficacia de los condones y visitas a farmacias o clínicas que los venden o regalan.
• Para fomentar las habilidades necesarias para evitar el sexo no deseado o desprotegido y para insistir en el uso de condones o anticonceptivos, se puede emplear juegos de rol que describan, demuestren y permitan que todos practiquen estas habilidades.
• Los jóvenes pueden practicar el uso correcto del condón abriendo el paquete y deslizando el condón sobre los dedos, o bien describiendo cada paso en el uso del condón.

¿cómo se implementan programas?

Cuando los programas eficaces se implementan, por lo general obtienen el apoyo necesario de las autoridades correspondientes, seleccionan y capacitan a los educadores con las características deseadas, realizan las actividades necesarias para reclutar y retener a participantes jóvenes y se apegan fielmente a los currículos. Los programas pueden ser eficaces tanto con educadores adultos como con educadores pares.

¿qué queda por hacer?

Los legisladores deben financiar y promover la implementación de programas de enseñanza con eficacia comprobada sobre la sexualidad y el VIH. Cualquier programa nuevo necesita incluir las características comunes de los programas eficaces.⁵ Los programas cuya eficacia no se ha comprobado deben ser evaluados. Para implementar ampliamente los programas con evidencia científica de eficacia para la enseñanza sobre la sexualidad y el VIH, debe contarse con el apoyo de las autoridades correspondientes, tales como directores de organizaciones para jóvenes, distritos escolares, directores de escuela y maestros. El personal o los maestros que realizan los programas deben recibir capacitación y apoyo con el fin de impartir los programas con fidelidad; esto supone apartar el tiempo suficiente en la clase o en la organización para poder brindar el programa.

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¿Quién lo dice?

1. Centers for Disease Control and Prevention. Youth risk behavior surveillance – United States, 2005. Surveillance Summaries. June 9, 2006. 2. Alan Guttmacher Institute. U.S. teenage pregnancy statistics: Overall trends, trends by race and ethnicity and state-by-state information. New York: The Alan Guttmacher Institute, 2004. 3. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 4. Kirby D, Lepore G, Ryan J. Sexual risk and protective factors: Factors affecting teen sexual behavior, pregnancy, childbearing and sexually transmitted disease: Which are important? Which can you change? Washington DC: National Campaign to Prevent Teen Pregnancy. 2005. 5. Kirby D, Laris BA, Rolleri L. Sex and HIV education programs for youth: Their impact and important characteristics. Washington DC: Family Health International, 2006. 6. Jemmott III, JB. Effectiveness of an HIV/STD risk-reduction intervention implemented by nongovernmental organizations: A randomized controlled trial among adolescents. Presented at the American Psychological Association Annual Conference. Washington DC: August, 2005. 7. DiClemente RJ, Wingood GM, Harrington KF, et al. Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. Journal of the American Medical Association. 2004;292:171-179. 8. Kirby D, Barth RP, Leland N, et al. Reducing the risk: Impact of a new curriculum on sexual risk-taking. Family Planning Perspectives. 1991;23:253-263. 9. Hubbard BM, Giese ML, Rainey J. A replication of Reducing the Risk, a theory-based sexuality curriculum for adolescents. Journal of School Health. 1998;68:243-247. 10. Kirby DB, Baumler E, Coyle KK, et al. The “Safer Choices” intervention: its impact on the sexual behaviors of different subgroups of high school students. Journal of Adolescent Health. 2004;35:442-452. 11. Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex: A randomized trial of HIV sexual risk-reduction interventions for young African-American adolescents. Journal of the American Medical Association. 1998;279:1529-1536. 12. St. Lawrence JS, Brasfield TL, Jefferson KW, et al. Cognitive-behavioral intervention to reduce African American adolescents’ risk for HIV infection. Journal of Consulting and Clinical Psychology. 1995;63:221-237.

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Preparado por Douglas Kirby PhD, ETR Associates Traducido por Rocky Schnaath Enero 2007. Hoja de Dato #10SR Se autoriza la reproducción (citando a UCSF) mas no la venta de copias este documento. También disponibles en inglés. Para recibir las Hojas de Datos por correo electrónico escriba a [email protected] con el mensaje “subscribe CAPSFS nombre apellido” ©Enero 2007, UCSF.

¿Cómo afectan los medicamentos opioides a las personas con VIH?

Elaborado por Kathleen Clanon, MD and Pamela DeCarlo | July 2017

¿Son los opioides una preocupación?

Sí. Los medicamentos que se recetan para aliviar el dolor como oxicodona, hidrocodona y metadona ayudan a millones de personas a manejar efectivamente el dolor crónico. Pero para algunas personas, estos opioides también se han convertido en una compleja trama de mal uso y  abuso que ha llevado a incrementos dramáticos en la incidencia de la adicción, sobredosis, infecciones por hepatitis B y C y posiblemente por el VIH. [1]

Las recetas de opioides en los Estados Unidos se duplicaron entre 2001 y 2015 sin que se haya registrado una disminución en la cantidad de dolor reportada. Solamente el uso de oxicodona e hidrocodona se triplicó entre 2000 y 2015. Los profesionales de la salud recetaron 259 millones de recetas de opioides para calmar el dolor en 2012—suficiente para cada uno de los adultos en los Estados Unidos. [2]

El Centro de Control y Prevención de Enfermedades recomienda no recetar opioides como terapia de primera línea o de rutina para el dolor crónico. [3]

¿Por qué preocupa el uso de opioides?

Falta de información sobre los riesgos de los opioides. Los opioides hacen que las personas se sientan bien y alivian el dolor sin producir efectos secundarios muy notorios. Además, los pacientes tienden a creer que los médicos no recetarían algo peligroso. A veces los pacientes no entienden que los opioides pueden crear dependencia física y algunos médicos tampoco entienden los riesgos o no los explican adecuadamente. Las personas a las que se les receta medicamentos opioides deben preguntar a sus proveedores de la salud si realmente son la manera más segura de manejar el dolor.

Sobredosis. De 2000 a 2014, hubo casi medio millón de muertes a causa de sobredosis de drogas, y más del 60 % de las muertes por sobredosis por drogas incluyeron un opioide. Todos los días, 46 personas mueren en los Estados Unidos por una sobredosis de opioides. [2]

Los opioides son altamente adictivos. Hasta un 25% de las personas que toman opioides a largo plazo terminan luchando con la dependencia. [4] Dicha dependencia se desarrolla extremadamente rápido. A los tres días de tomar opioides, ya existe la posibilidad de que su consumo se vuelva crónico y el riesgo aumenta rápidamente con cada día de uso. [5]

¿Cómo afectan los opioides a las personas viviendo con VIH?

Posibles efectos negativos para las personas viviendo con VIH. Para las personas que viven con el VIH (PVV), el uso de opioides a largo plazo puede provocar depresión, contribuir recaídas en el uso de substancias y hasta incrementar el dolor crónico. [6]

Incremento de conductas riesgosas. Igual que el alcohol y otras drogas, los opioides por receta pueden interferir con el juicio y la capacidad de tomar decisiones, y pueden resultar en que una persona haga cosas que en otras circunstancias no haría. Al disminuir las inhibiciones, los opioides pueden fomentar conductas riesgosas (como tener sexo sin protección o compartir jeringas) que incrementan el riesgo de transmitir o contraer el VIH o la hepatitis C o B [7].

Transición a inyectarse y a la heroína. La epidemia del mal uso de opioides por receta ha llevado a muchas personas a inyectarse por primera vez. Casi un 80% de los nuevos consumidores de heroína reporta haber usado opioides por receta primero. [8]

¿Cuáles son los riesgos para las personas viviendo con VIH?

Uso a largo plazo de opioides. Hasta un 85% de PVV sufren dolores crónicos. A muchas se les receta opioides para aliviar el dolor. Los efectos secundarios del consumo de opioides a largo plazo incluyen: una disminución en la libido, menos testosterona, depresión, arritmia y problemas neurológicos. El uso continuo de opioides para calmar el dolor puede en cambio incrementar el dolor crónico en PVV en vez de aliviarlo.

Abuso de opioides. El uso problemático de opioides por receta puede ser común en PVV, especialmente si tienen una historia de abuso de drogas, problemas de salud mental y poca adherencia al tratamiento antirretroviral. Una investigación demostró que un 62% de PVV que consumen opioides por receta los toman de manera problemática. [9]

Recaídas y sobredosis. Para PVV con una historia de abuso de alcohol y de drogas, los opioides pueden ocasionar recaídas en el uso de sustancias. Las sobredosis accidentales son comunes, sobre todo cuando los opioides se mezclan con alcohol o benzodiazepinas (como Valium o Xanax), antidepresivos o medicamentos anticonvulsivos. [3]

Atención para el VIH. Los factores específicos del cuidado médico del VIH pueden determinar si los profesionales de la salud observan o no las normas federales para recetar opioides. Por ejemplo, el personal médico puede valorar la retención de pacientes con VIH o un sentido de alianza con sus pacientes como más importante que lineamientos federales conservadores acerca de recetar opioides. Capacitaciones especializadas sobre el recetar opioides podrían ser necesarias para los profesionales de la salud que atienden a las personas con VIH.

¿Cuáles son los riesgos para personas que están en riesgo de adquirir el VIH?

Falta de conocimiento y de programas relacionados con el uso más seguro de drogas inyectables. La epidemia de opioides ha ocasionado un aumento en el consumo de drogas inyectables. Los nuevos consumidores de estas drogas suelen ser personas de raza blanca que viven en zonas rurales o suburbanas, tienen poco conocimiento sobre prácticas de inyección más seguras y sobre los riesgos de contraer hepatitis o VIH y tienen poco (o nulo) acceso a programas educativos y a servicios para consumidores de drogas inyectables como la distribución de jeringas esterilizadas. [11] Estos factores fomentan las condiciones para la propagación rápida del VIH en comunidades específicas.

Hepatitis C. Actualmente, la transmisión de hepatitis C es un riesgo significativo para personas que se inyectan, sobre todo entre los jóvenes y los habitantes de pueblos pequeños y zonas rurales en los Estados Unidos que se inyectan opioides. En 2013, hubo 30,000 nuevos casos de hepatitis C y un incremento de infecciones de hepatitis C en 28 Estados, lo que equivale a un incremento de más de un 150% desde 2010 [11].

Transmisión potencial rápida del VIH. En 2015, el primer brote de VIH vinculado a la inyección de opioides por receta ocurrió en una zona rural del Estado de Indiana. El VIH se propagó rápidamente dentro de esta pequeña comunidad, con 135 pesonas seropositivas, el 80% de las cuales reportaron haber disuelto e inyectado pastillas de oximorfona.

¿Qué debe hacerse?

Ante el dramático aumento de recetas, uso, adicción y sobredosis de opioides en los años recientes, varias agencias federales, estatales y locales han desarrollado normas, reglamentos y programas para promover la seguridad. En 2016, el Centro de Control y Prevención de Enfermedades elaboró una serie de normas con la finalidad de mejorar la comunicación entre profesionales de la salud y pacientes sobre los riesgos y los beneficios de los opioides para el dolor crónico y para mejorar la seguridad y eficacia del tratamiento para el dolor, así como para reducir los riesgos asociados a terapias a largo plazo con opioides, incluyendo la adicción, sobredosis y mortalidad.

Profesionales de la salud

Cuidado o manejo del dolor sin opioides. Los profesionales que atienden a PVV deben tomar en cuenta la edad, género, condición socio-económica, salud mental y consumo de drogas de la persona, ya que el manejar el dolor sin tener en cuenta esas variables puede tener un éxito limitado. El Centro de Control y Prevención de Enfermedades recomienda no recetar opioides como terapia de primera línea para el dolor crónico, por lo que los profesionales deben considerar otros medios para manejar el dolor. La terapia cognitiva conductual, fisioterapia, hipnosis o marihuana para uso medicinal también pueden aliviar el dolor en las personas con VIH. [13]

Prevención de sobredosis. Si profesionales y pacientes deciden usar opioides, los proveedores deberían discutir y proveer a los pacientes material escrito sobre los riesgos de la dependencia y la sobredosis, así como considerar prescribir también naloxona para revertir los efectos potencialmente fatales de una sobredosis.

Personas que viven con el VIH

PVV a las que se les receta opioides deben discutir cualquier inquietud con su médico y preguntar sobre métodos para manejo del dolor que no incorporan opioides. En caso de recetárseles opioides, deberán usarlos por la menor cantidad de tiempo posible y ser conscientes de que se puede crear dependencia casi inmediatamente, dentro de tres días de su consumo. [5] PVV que han venido tomando opioides durante mucho tiempo deberían hablar con su médico sobre cómo pueden irlos dejando o reducir su consumo.

Políticas sanitarias

Sabemos cómo prevenir el VIH y contamos con múltiples intervenciones eficaces para prevenirlo. El brote del VIH en personas que se inyectan drogas en zonas rurales de Indiana demuestra lo que puede pasar cuando el gobierno estatal y las comunidades no invierten en la prevención. Tenemos que comprometernos a promover la educación y los servicios de reducción de riesgos como programas de acceso a jeringas, prevención de sobredosis, incluyendo acceso a naloxona y programas de rehabilitación. [14]

Aunque el conocimiento científico acumulado durante años demuestra la necesidad, la eficacia y los beneficios económicos de programas para personas que se inyectan drogas, aún existen barreras políticas y legislativas para su implementación. Tenemos que apoyar, proteger y ampliar la legislación actual y los programas que promueven la salud y el bienestar de las personas que consumen y usan mal los opioides por receta, incluidas las personas que se inyectan drogas y sus parejas.

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¿Quién lo dice?

1. RTI International. Opioids In America: A complex crisis. A comprehensive response. www.rti.org/sites/default/files/brochures/rti_opioids_in_america.pdf
2. CDC. Opioid painkiller prescribing: Where you live makes a difference. CDC Vital Signs. July 2014. www.cdc.gov/vitalsigns/opioid-prescribing
3. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR. 2016;65:1-49.
4. CDC. Injury prevention and control: Opioid overdose. Drug overdose deaths in the United States continue to increase in 2015. www.cdc.gov/drugoverdose/epidemic/
5. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use — United States, 2006–2015. MMWR. 2017;66:265–269. http://dx.doi.org/10.15585/mmwr.mm6610a1
6. Liu B, Liu X, Tang SJ. Interactions of opioids and HIV infection in the pathogenesis of chronic pain. Front Microbiol. 2016;7:103.
7. Zule WA, Oramasionwu C, Evon D, et al. Event-level analyses of sex-risk and injection-risk behaviors among nonmedical prescription opioid users. Am J Drug Alcohol Abuse. 2016;42:689-697.
8. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
9. Turner AN, Maierhofer C, Funderburg NT, et al. High levels of self-reported prescription opioid use by HIV-positive individuals. AIDS Care. 2016;28:1559-1565.
10. Starrels JL, Peyser D, Haughton L, et al. When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers. Subst Abus. 2016;37:148-153.
11. National Institute on Drug Abuse. Prescription opioids and heroin. NIDA Research Report Series. 2015. www.drugabuse.gov/publications/research-reports/prescription-opioids-heroin
12. Conrad C,  Bradley HM,  Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone — Indiana, 2015. MMWR. 2015;64:443-444. www.cdc.gov/mmWr/preview/mmwrhtml/mm6416a4.htm
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Gracias a Rachel Anderson, Emily Behar, Neisha Becton, Holvis Delgadillo, Linda Gowing, Barbara Green-Ajufo, Renata Henry, Daryl Mangosing y Savannah O’Neill por revisar esta hoja informativa. Kathleen Clanon está afiliada con Alameda County Health Care Services Agency. Agradecemos la reproducción y la difusión de esta hoja, siempre que sea de manera gratuita y que se cite a la University of California San Francisco. ©2017, University of CA. Preguntas y comentarios pueden enviarse a [email protected].

Esta publicación es un producto del Centro de Investigación sobre la Prevención con el apoyo de los Centros de Control y Prevención de Enfermedades (Cooperative Agreement Number 5U48DP004998).